Knowing Endangerment - Hanford Challenge

Knowing Endangerment:
WORKER EXPOSURE TO TOXIC VAPORS
AT THE HANFORD TANK FARMS
September 2003

The “Investigation of Events” chapter of the 2001 CH2M Hill Hanford Group (CHG) Conduct of Operations
Manual states that a systematic investigation should occur when workplace conditions are abnormal or
unexplained, or hazardous material limits are exceeded. According to CHG procedure, the investigation should
involve collecting data on the initial conditions, taking statements from involved personnel, and obtaining computer
printouts, copies of log books, work permits, and procedures. The actual responses to the event or abnormality
should be documented and then compared to the expected responses, and detrimental effects of safety issues should
be determined. Once the investigation and reconstruction of the event has occurred, the root cause(s) of the event
should be determined, in order to preclude recurrence of the event. Ultimately, a final Investigation Report should
be prepared, and distributed as a Lessons Learned to those who may benefit from the information.
It is apparent that neither the U.S. Department of Energy nor CHG are willing to truly investigate the recent
abnormal events occurring at the Hanford Nuclear Reservation in Eastern Washington, involving dozens of tank
farm workers being exposed to toxic chemical vapors and requiring medical attention. The Hanford Joint Council, a
mediation board responsible for investigating and resolving conflicts between workers and DOE contractors, was
recently eliminated by the Department of Energy. Thus, the Government Accountability Project (GAP), at the
request of several tank farm workers, has endeavored to conduct its own investigation, using CHG’s Investigation
Criteria. GAP has compiled the following information through Freedom of Information Act (FOIA) requests,
through interviews with tank farm workers, health care providers, toxicologists, and others, and through review of
incident reports, deposition testimony, Problem Evaluation Requests, Occurrence Reports, Lessons Learned,
newsletters, newspaper stories, and other reports and background information provided to us and publicly available.
Though the information presented below may not be exhaustive, for example, if information has been withheld
through FOIA exemptions, it does form a minimum baseline of information from which it is possible to draw
conclusions.
It is GAP’s hope that this Investigation Report will trigger the DOE, CHG, and government policy makers to take
swift and decisive steps to protect the health and safety of Hanford’s Tank Farm workers.
This report was prepared by Clare Gilbert and Tom Carpenter of GAP’s Nuclear Oversight Campaign with
assistance provided by interns Billie Morelli, Jessica Barkas, Susannah Dougherty, Archana Dayalu, GAP’s
Jennifer Slagle, and Atis Muehlenbachs. GAP also thanks everyone who reviewed and commented upon drafts of
the report.
The Government Accountability Project (GAP) is a private, non-profit organization that advocates on behalf of
employees who witness and disclose fraud, waste and abuse, mismanagement, threats to public and worker health
and safety, and environmental violations. GAP has represented dozens of Hanford employees in various
whistleblower lawsuits since 1998.
Government Accountability Project
Nuclear Oversight Campaign
www.whistleblower.org
The photograph on the cover page was taken by Alan Berner of The Seattle Times
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TABLE OF CONTENTS
I. EXECUTIVE SUMMARY 1
II. BACKGROUND 4
A. HANFORD TANK FARMS AND CHEMICAL VAPORS 4
B. HEALTH EFFECTS OF TANK VAPORS 6
EXPOSURES AND SYMPTOMS 6
THE 1997 PNNL VAPOR REPORT 6
C. HISTORICAL EXPOSURES AND RESPONSES 7
THE 1992 DOE TYPE B INVESTIGATION 7
THE HEWITT REPORT 8
III. CURRENT CONDITIONS 10
A. RECENT EXPOSURES 11
B. CHEMICAL VAPOR MONITORING - CHG PROCEDURES AND PRACTICES 12
MONITORING IN PROCEDURE 12
MONITORING IN PRACTICE 13
C. PERSONAL PROTECTIVE EQUIPMENT – CHG PROCEDURES AND PRACTICES 19
D. CHG RESPONSE TO CHEMICAL VAPOR EXPOSURES AND CONCERNS 23
SUPPRESSED MONITORING DATA 25
A CHILLED WORK ENVIRONMENT 28
IV. HANFORD ENVIRONMENTAL HEALTH FOUNDATION 29
V. SYSTEMIC NATURE OF PROBLEM 35
VI. REMEDIES AND POSSIBLE SOLUTIONS 38
APPENDIX A: EXPOSURE EVENTS REQUIRING MEDICAL ATTENTION: 1987 - 1992 41
APPENDIX B: EXPOSURE EVENTS REQUIRING MEDICAL ATTENTION: 2002 - 2003 42
APPENDIX C: TANK VAPOR MONITORING EQUIPMENT 45
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ACRONYMS
> D Less than detectable level (on monitoring equipment)
ACGIH American Conference of Governmental Industrial Hygienists
BHS Behavioral Health Services (at HEHF)
CAS Chemical Abstracts Service
CCC Command Control Center
CCSI Contract Claims Services, Inc.
CHG CH2M Hill, Hanford Group, Inc. (a DOE contractor)
CT-ROSE Computed Tomography-Remote Optical Sensing of Emissions
DOE United States Department of Energy
DOE-RL US Department of Energy, Richland Field Office
DST Double Shell Tank
DRI Direct Reading Instrument
FOIA Freedom of Information Act
FY Fiscal Year
GAP Government Accountability Project
HAMTC Hanford Atomic Metal Trades Commission
HASP Health and Safety Plan
HAZWOPER Hazardous Waste Operations and Emergency Response
HEHF Hanford Environmental Health Foundation (a DOE contractor)
HEPA High-Efficiency Particulate Air
HLW High Level Waste
HPT Health Physics Technician
IDLH Immediately Dangerous to Life or Health
IH
Industrial Hygienist/ Industrial Hygiene
IHT Industrial Hygiene Technician
IME Independent Medical Examiner
JHA Job Hazard Analysis
Kadlec Local hospital in Richland
L & I Labor and Industries (Workers Compensation)
LEL Lower Explosive Limit (Flammable gas level)
NCO Nuclear Chemical Operator
NDMA n-nitrosodimethylamine
NH 3 Ammonia
NIOSH National Institute for Occupational Safety and Health
NPO Nuclear Process Operator
NWC Nuclear Weapons Complex
OP-FTIR Open Path-Fourier Transform InfraRed
OSHA Occupational Safety and Health Administration
PAPR Powered Air Purifying Respirators
PEL Permissible Exposure Limit
PER Problem Evaluation Request
PID Photo-ionization detector
PNNL Pacific Northwest National Laboratory (operated by Battelle)
PPE Personal Protective Equipment
ppm Parts per million
ppb Parts-per-billion
ppbRAE RAE Systems parts per billion photo-ionization detector (PID) organics monitor
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SCBA
SST
TLV
TOC
TWINS
VOC
WHC
Self Contained Breathing Apparatus (or supplied air)
Single-Shell Tank
Threshold Limit Values
Total Organic Carbon
Tank Waste Information Network System
Volatile Organic Compounds
Westinghouse Hanford Corporation (a DOE contractor)
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KNOWING ENDANGERMENT:
WORKER EXPOSURE TO TOXIC VAPORS AT THE HANFORD TANK FARMS
I. EXECUTIVE SUMMARY
The Hanford Nuclear Reservation, located in southeastern Washington state, is a former nuclear
weapons production facility owned by the U.S. Department of Energy (DOE), and operated under
contract by private companies. The legacy of Hanford‟s plutonium production operations is a
staggering quantity of deadly high-level radioactive and chemical byproducts, the worst of which, an
estimated 53 million gallons of nuclear waste, are stored in 177 underground tanks. The tanks are
arranged into eighteen farms, known as “tank farms,” and managed primarily by DOE contractor
CH2M Hill Hanford Group, Inc. (CHG). The high level waste forms noxious vapors in the
headspace of the tanks, which must vent through openings in the tanks to the atmosphere to prevent
pressure buildup and possible explosion or tank rupture. This report focuses on the chemical vapors
emitting from the high level waste tanks, the Hanford workers exposed to those vapors, and the
willingness of the DOE and CHG to sacrifice worker health and safety in exchange for meeting
“accelerated cleanup” deadlines at minimum financial cost.
Over 1200 chemicals have been documented in the vapors contained within Hanford‟s tank
headspaces, any number of which can and do escape through various tank equipment. Workers
exposed to the tank vapors have suffered numerous health effects: nosebleeds, persistent headaches,
tearing eyes, burning skin and lungs, coughing, difficulty breathing, sore throats, the need to
constantly clear their throats, expectorating, dizziness, nausea, and increased heart rates. But the
more serious health impacts may be long term in nature. DOE‟s Pacific Northwest National
Laboratory (PNNL) concluded in a 1997 draft report that the risk of contracting cancer from
exposure to these chemical vapors could be as high as 1.6 in 10.
As DOE and CHG rush to pump and treat the high level waste to meet the DOE‟s new “accelerated
cleanup” deadlines of faster, cheaper cleanup, worker exposures to chemical vapors have
skyrocketed, with at least 45 documented chemical vapor exposure incidents involving over 67
workers requiring medical attention between January 2002 and August 2003. There were an
additional 75 complaints of tank vapor odors in the same time span.
The DOE is conspicuously silent in the face of these rampant violations of worker health and safety.
The lack of DOE oversight means that CHG is able to put on appearances of addressing the chemical
vapor problem, without really making any significant changes:
CHG‟s chemical vapor monitoring is woefully inadequate; its equipment can only
accurately test for a small fraction of the over 1200 chemicals potentially coming out
of the tanks and monitoring occurs only a small fraction of the time workers are in the
field. CHG‟s recently acquired RAE Systems parts-per-billion (ppb) organics
monitor was found to have such poor performance in tests for agent sensitivity that
the U.S. Army discontinued testing of its ability to detect the presence of airborne
chemical weapons.
Despite knowledge of the soaring rate of chemical vapor exposures CHG refuses to
let employees concerned about their own health and safety use supplied air
respirators, and is, in fact, planning to reduce the amount of respiratory protection
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used in the tank farms and reduce the amount of administrative controls designed to
protect workers. Already, CHG has done away with the “buddy system” whereby all
work is performed in pairs, so that if one person is injured, there is another person on
hand to provide assistance. CHG repeatedly has sent workers into known dangerous
conditions wearing only dust masks as respiratory protection. The majority of
workers in the Hanford tank farms wear no respiratory protection whatsoever.
CHG either has intentionally falsified, covered-up, and skewed monitoring data or
has maintained such haphazard chemical vapor monitoring procedures that the
apparent falsifications and cover-ups are normal operating procedure. Excessively
high contaminant readings on instruments frequently go unrecorded and
unacknowledged by CHG, and health-affected tank farm workers are left with no
dose record.
CHG relies on an outdated, flawed 1996 report as a basis of several of its tank vapor
monitoring and industrial hygiene practices, despite professional criticism that this
report is no longer valid due to recent tank pumping and waste disturbances activities.
Workers who raise concerns and insist on protecting themselves from chemical
vapors have found themselves being denied overtime work, which can comprise over
30% of a tank farm worker‟s annual income. They have been subjected to retaliation,
harassment, and taunting by their peers and supervisors, which effectively creates a
chilling atmosphere and discourages other workers from raising concerns.
The Hanford Atomic Metal Trades Council (HAMTC), the bargaining agent representative of all
unionized Hanford workers, recently considered withdrawing its support for CHG‟s Voluntary
Protection Program (a DOE sponsored program that allows self regulation of worker health and
safety), citing, among other things, a 300% increase in safety concerns in six months, “that
employees feel cover-ups are taking place with limited critiques, no formal investigations or lessons
learned,” and a “production over safety” environment created by CHG.
Additionally, certain physicians and mental health counselors at the medical facility on site, the
Hanford Environmental Health Foundation (HEHF), compound the problem for a tank farm worker
seeking protection from chemical vapors. GAP has received several reports and documentation that
HEHF management has:
dismissed chemical vapor related symptoms as imagined or the result of allergies;
designed policies of automatic referral to a mental health counselor for a host of
questionable reasons;
shredded and altered patients‟ progress notes;
pressured workers to accept tank farm restrictions designed by tank farm contractors
and suggested that the worker‟s job is at stake if they refuse;
pressured HEHF health care providers not to write “recordable” medical restrictions
for workers;
prohibited patients from having a union steward, friend, or family member
accompany them during medical visits.
The 45 recent exposures in the past 20 months represent a 750% increase in the rate of similar
exposures that triggered the last major DOE investigation into Hanford‟s chemical vapor exposures.
When a former Assistant Secretary of Labor for OSHA reviewed that 1992 DOE Type B
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Investigation into 16 chemical vapor incidents requiring medical attention over a 55 month (4½ year)
span, he commented that,
The failure of those in responsible management charge to assign resources to this
problem in the presence of repeated violations would, without any doubt, have been
viewed by OSHA as willful violations of the [Occupational Safety and Health] Act
and subject to possible criminal penalties. This conclusion would probably have been
reached by the end of 1987 when three [worker exposure] episodes had occurred, but
certainly by 1989 when the episodes reoccurred. The absence of high priority for
solving this problem in 1990, with attendant lack of professional staff and resources
could well put someone on trial for criminal behavior [had the occurrences been
subject to OSHA enforcement and penalties]. Also, in 1989 with the reoccurrence of
the episode, [an OSHA finding of] “imminent danger” and a series of restrictive
procedures akin to closure of a manufacturing facility probably would have been
invoked. 1
Yet the Occupational Safety and Health Administration (OSHA) does not have jurisdiction at the
Hanford site or any other DOE site. Today, tank farm workers are left to fend for themselves as the
DOE chooses not to exercise effective contractor oversight to ensure a quicker, cheaper „cleanup.‟
In 2000, Congress enacted legislation in response to past injuries to workers at DOE sites such as
Hanford. The legislation provides compensation to atomic workers in places like Hanford because of
past exposures to radiation. Under this program, workers who can show that they were exposed to
radiation and have contracted cancer can, in most instances, collect a one time payment of
$150,000.00 and are eligible for lifetime medical care at taxpayer expense.
This report documents that Hanford is in the process of creating a new generation of sick and injured
workers. The de facto policy of placing production over safety that caused past ailments remains
firmly in place at Hanford. And once again, workers are the ones who will have to live, and die, with
the consequences of that policy.
1 Morton Corn, Professor and Director, Division of Environmental Health Engineering, The Johns Hopkins
University, School of Hygiene and Public Health, letter to T. O‟Toole, OTA, July 27, 1992, Cited in U.S. Congress,
Office of Technology Assessment, HAZARDS AHEAD: MANAGING CLEANUP WORKER HEALTH AND SAFETY AT THE
NUCLEAR WEAPONS COMPLEX 55-56 (OTA-BP-O-85) (Feb. 1993).
3

II.
BACKGROUND
A. Hanford Tank Farms and Chemical Vapors
High level nuclear waste (HLW) is recognized as one of the most dangerous substances known to
humankind. It is created by processing irradiated nuclear reactor fuels in chemical solutions to
recover plutonium for weapons production. In addition to being radioactive, HLW contains over one
thousand chemicals. One Dixie cup full of HLW, placed in a crowded area such as a theatre, could
kill nearly everyone within minutes. 2 The Hanford Nuclear
Reservation (Hanford) stores 53
million gallons of HLW in 149
single shell and 28 double shell
underground carbon steel storage
tanks, ranging between 55,000
and 1,000,000 gallon capacity
and arranged in 18 groupings
called „tank farms.‟ The HLW
stored at the tank farms is
chemically complex, due to the
various reprocessing techniques
and the wide array of substances
added to the tanks over the
years. 3 When irradiated fuel was
reprocessed only shortly after
irradiation, its waste liquid
contained heat-generating
radionuclides that made the
waste so thermally hot that it
would periodically burst into a
violent surging boil that
pressurized the tanks by
releasing gases more than 20
times the normal rate. Water
was added to cool the waste. 4
These various additions and the synergistic effects of the organic and inorganic chemicals and the
radiation have transformed Hanford‟s HLW into a veritable “witches brew” of toxins. The waste in
each tank forms varying mixtures of liquids and solids, including thick sludge, a dry, crystallized
“saltcake,” liquid, and vapors. The tanks have to be monitored constantly. Probes detect leaks and
measure temperatures, liquid levels, and other parameters associated with tank monitoring. There are
risers that penetrate the tank dome and surrounding areas, and several process and service pits (called
pump pits) are associated with the tanks. The pits are covered with heavy cover blocks and sealed
2 Robert Alvarez, The Legacy of Hanford, THE NATION, Aug. 8, 2003, 31 – 35.
3 Roy E. Gephart, Pacific Northwest National Laboratory [hereinafter PNNL], HANFORD: A CONVERSATION ABOUT
NUCLEAR WASTE AND CLEANUP 5.16 (2002).
4 Id.
4

with foam. Waste routing equipment includes piping, pumps, valves, leak detection equipment,
flexible jumper, and associated pump and valve pits. 5
Because the chemical composition of Hanford‟s underground tanks is so
dynamic in nature, the tanks are designed to vent in order to prevent excess
vapors from over-pressurizing the tank head space and posing potentially
serious safety consequences, such as explosions and fires. The single-shell
tanks (SST) built before 1955 allow gases to vent to the atmosphere via
breather “gooseneck” pipes. Thirteen of the SSTs and all of the double shell
tanks were fitted with active ventilation systems and high-efficiency particulate
air (HEPA) filters to remove particulates. 6 The remaining 136 of Hanford‟s
SSTs are passively vented. 7 Vapors from these tanks are released at breaks in
containment, breather filters, pump pits, saltwell pits, and other unsealed tank
penetrations. Tank venting and chemical vapor exposures are influenced by the
following: pumping or other waste intrusive activities; meteorological
conditions (temperatures above 60 degrees F and changing barometric
pressure); height of liquid in tank; hydrogen/flammable gas concentration; and
activities conducted by tank farm employees (opening cabinets, pit entry,
turning valves, flushing, performing monitoring phase). 8 Most reports of odor
problems and exposure to chemical vapors and gases occur in the single shell
tank farms, since they are older, not as well contained, and have passive breather filters. 9
“Hanford waste tanks are, in
effect, slow chemical
reactors in which an
unknown but large number
of chemical (and
radiochemical) reactions are
running simultaneously.
Over time, the reaction
dynamics and compositions
have changed and will
continue to change . . . .”
- Art. Janata et. al, REPORT OF THE AB
INITIO TEAM FOR THE HANFORD TANK
CHARACTERIZATION AND SAFETY ISSUE
RESOLUTION TEAM , cited in Gephart,
HANFORD: A CONVERSATION
ABOUT NUCLEAR WASTE AND
CLEANUP 5.16
The limited tank headspace sampling that has been conducted demonstrates that the headspace
vapors may contain any number of over 1200 different organic and inorganic chemicals, in addition
to radiation. 10 Chemicals potentially venting from the tanks include: carcinogens such as radioactive
particles, benzene, chloroform, and potential carcinogens, such as n-nitrosodimethylamine (NDMA),
acetone-trile, carbon tetrachloride, and ethylene-dibromide (the last 4 of which are also liver toxins).
Other toxic compounds present include: ferrocyanide, hydrogen-sulfide, hydrogen-cyanide, sulfurdioxide,
sulfur-trioxide, hydrogen-fluoride, nitrous-oxide, hydrazine, butanol, acetone, hexane,
xylene, carbon monoxide, methylamine, and ammonia. 11 Methylamine smells like ammonia, but is
5 Don Quilici, CIH, CSP, Baseline Hazard Assessment: Hanford Tank Farms 2003 E / 200 W Areas, 42 (Submitted
to Westinghouse Hanford Company, Contract No. MJG-SCV-165890) (Oct. 15, 1993).
6 UNITED STATES DEPARTMENT OF ENERGY – RICHLAND FIELD OFFICE [hereinafter DOE-RL], TYPE
B INVESTIGATION OF HANFORD TANK FARM VAPOR EXPOSURES 3-2 (April 1992) [hereinafter 1992
TYPE B INVESTIGATION].
7 CH2M HILL HANFORD GROUP [hereinafter CHG], TANK FARMS HEALTH AND SAFETY PLAN 30
(HNF-SD-WM-HSP-002, Rev. 4) (Mar. 2002) [hereinafter HASP].
8 Kathie Lavaty, Prezant Associates, Report Of CH2M Hill Hanford Group Tank Vapor Concern Evaluation, March
11 Through March 29, 2002 Observations, Discussion And Recommendations, 10 (April 11, 2002).
9 PNNL, HANFORD ENVIRONMENTAL HEALTH FOUNDATION [hereinafter HEHF], EXPOSURE-BASED
HEALTH ISSUES PROJECT REPORT: PHASE I OF HIGH-LEVEL WASTE TANK OPERATIONS,
RETRIEVAL, PRETREATMENT, AND VITRIFICATION EXPOSURE-BASED HEALTH ISSUES ANALYSIS
6.1 (PNNL-13722) (Nov. 2001).
10 L.M. Stock & J.L. Huckaby, PNNL, A SURVEY OF VAPORS IN THE HEADSPACES OF SINGLE-SHELL
WASTE TANKS, 4 (PNNL-13366) (Oct. 2000); See also, The Tank Waste Information Network System (TWINS)
database, which contains tank waste and vapor characterization information on all the Hanford Tanks, available at
http://twinswe.pnl.gov. Visitors to the TWINS database must first submit an application to DOE at
Melvin_R_Adams@rl.gov, and identify name, organizational affiliation, phone number, email address, and the
reason for requesting access.
11 CHG, HASP, supra note 7, at 9.
5

not detected on an ammonia monitor. These and hundreds more chemicals can be released into the
workers‟ breathing environment via tank venting. 12
B. Health Effects of Tank Vapors
Workers exposed to
tank vapors experience
health effects such as
nosebleeds, persistent
headaches, tearing eyes,
sticky eyes, burning
skin, contact dermatitis,
increased heart rate,
difficulty breathing,
coughing, sore throats,
constant need to clear
throats, expectorating,
dizziness, nausea, and
metallic taste in mouth
and on lips.
Exposures and Symptoms
The chemical vapors emanating from the Hanford tanks have various described odors: ammonia,
rotten eggs, wine, old socks, musty, diaper pail, garlic, whisky, gasoline, wet cardboard, mint, fruit,
chloroform, and butter. Other chemicals coming off the tanks have no odors at all, such as n-
nitrosmethanamine (a carcinogen and liver toxin), propane, propene (asphyxiant),
trichlorofluoromethane (asphyxiant), nitrous oxide, and carbon monoxide (poison).
The symptoms of workers exposed to tank vapors may best be
illustrated in case studies of a few tank farm workers. One worker was
exposed for approximately twenty minutes to high levels of what his
co-workers described as an ammonia odor, though he could not smell it
as he had a head cold. When he left the area, all of his exposed skin
immediately became bright red and he had a putrid, metallic taste in his
mouth. He later suffered a sore throat and vocal cords, recurring
nosebleeds, and the need to constantly clear his throat. He suffered a
series of headaches and for five months his “lungs just wept,” coughing
up a white, milky substance, his voice underwent a permanent change,
and he woke up in the middle of the night in severe respiratory distress
and was rushed to the emergency room for treatment.
Another worker suffered five separate vapor exposures between
January and February 2002. He describes opening cabinets attached to
tank piping, only to be overcome by vapors that were so powerful he
stumbled backwards and had trouble inhaling. This worker suffered burning nasal passages,
nosebleeds, a metallic taste on his lips, rashes, welts, and contact dermatitis which took several
months to heal with prescription medication. Since these exposures he has become sensitive to
gasoline, bleach, ammonia, some paints and deck stain.
Yet another worker‟s 2002 exposures resulted in burning sinuses, nosebleeds, sore throat, hoarseness,
tearing eyes, nausea, dizziness and increased heart rate. Three physicians each separately concluded
that his sinus problems and nosebleeds were the likely result of his exposures to tank vapors.
The 1997 PNNL Vapor Report
In 1997, Battelle's Pacific Northwest National Laboratory (PNNL) issued to DOE a draft report
examining the potential health risks associated with the vapors released from a single Hanford tank,
C-103. 13
12 Id. at 9 - 10.
13 A. D. Maughan, J.G. Droppo, K.J. Castleton, PNNL, HEALTH RISK ASSESSMENT FOR SHORT- AND
LONG-TERM WORKER INHALATION EXPOSURE TO VAPOR-PHASE CHEMICALS FROM THE SINGLE-
SHELL TANK 241-C-103, DRAFT (Mar. 1997) [hereinafter 1997 C-103 VAPOR HEALTH RISK
ASSESSMENT]
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The PNNL report examined emissions from Tank C-103 and found that 221 gases released from C-
103 were identified from the Hanford Tank Waste Information Network System (TWINS). The goal
of the study was to determine the health risks from inhalation of the vapors exhausted from two
exhauster tank stack configurations (one bent at the top and one straight stack) and whether worker
exposures to the tank‟s chemical vapors were within OSHA guidelines. 14
The PNNL study identified major uncertainties in knowledge pertaining to
toxicity effects of many of the chemicals detected in the tank. The report
emphasizes the synergistic effects of the chemicals upon each other,
asserting that “many of the vapor-phase chemicals are in a volatile, reactive
state” and that “the potential for synergism increases exponentially with the
number of compounds making up the exposure.” 15 According to the report,
tank farm workers
may be at potentially greater risk than is commonly held for the
Hanford Site. The scenario becomes more realistic as the
maintenance of tank chemicals shifts to remediation. It is further
unclear whether cancer is induced after chronic exposure or
perhaps after a single release. In any case, because the latent
period for manifesting most forms of cancer is approximately 20
years, it will be unlikely that the etiology will be traced to any
given event. 16
The PNNL scientists
concluded that the risk
of contracting cancer
from exposure to the
chemical vapors from
tank C-103 could be as
high as 1.6 in 10, and
that even this estimate
“may not represent the
highest potential risks.”
They further asserted
that if other nearby
tanks were to vent to the
outside, which all
Hanford tanks do, then
“the risks would be
increased.”
The report went on to state that while a tank worker may not receive a chemical vapor dose in excess
of OSHA regulations (because of OHSA‟s methodology for determining exposures to mixtures of
chemicals), “the worker would be at risk of developing cancer, or other chronic disease, from the
exposure.” 17
C. Historical Exposures and Responses
The 1992 DOE Type B Investigation
In the 55 months between July 1987 and January 1992, there were 16 incidents where tank farm
workers were exposed to chemical vapors and required medical attention (see Appendix A). This
series of events triggered investigations by the U.S. Senate Committee on Governmental Affairs, the
DOE‟s Office of Environment, Safety and Health, DOE‟s Office of Inspector General, and, upon
invitation, the Occupational Safety and Health Administration (OSHA). 18 These investigations found
that DOE contractors were failing to provide adequate worker protection after repeated internal
14 Id.
15 Id. at 7.2.
16 Id. (emphasis added).
17 Id. at 8.1.
18 Robert Alvarez, Professional Staff, U.S. Senate Committee on Governmental Affairs, Memorandum to Files,
Environmental, Safety and Health Issues at the U.S. Department of Energy’s Hanford Site, April 10, 1993.
7

warnings by safety experts, threatening workers with job loss if they reported injuries, and knowingly
submitting false information regarding lost-time injuries. 19
The 16 exposures also triggered a large scale investigation by the DOE and culminated in a highlevel,
comprehensive Type B Investigation of Hanford Tank Farms Vapor Exposures, released in
April of 1992. 20 The Type B Investigation found numerous problems underlying the then primary
tank farms contractor‟s (Westinghouse Hanford Corporation (WHC)) inability to protect its tank
farm workers, and concluded there were 37 “judgments of need” to be translated into corrective
action. 21 The Type B Investigation resulted in the implementation of supplied air for workers at 84
of the 177 tanks, constant air monitoring by Industrial Hygiene Technicians (IHT) at all sites where
supplied air was not being used, requirements to characterize of tank contents and vapors, the
creation and implementation of a tank farms Health and Safety Plan (HASP), and a plan to install
permitted ventilation on single shell tanks. Reports of exposures decreased as a result of the
implementation of these controls. Unfortunately, this did not last long.
The Hewitt Report
In July 1996, Westinghouse released a report, Tank Waste Remediation System Resolution of
Potentially Hazardous Vapors Issue, authored by an employee named Elton Hewitt. 22 The Hewitt
report concluded that due to implementation of controls around potential vapor release points,
characterization of tank contents and vapors, and “as a result of better communications regarding
vapor odors and risks” following the Type B Investigation, “employee exposure incidents have
virtually ceased” and the vapor problem had been “resolved.” 23
In reaching this conclusion, Hewitt noted that while ammonia and nitrous oxide compounds routinely
were present in concentrations greater than 5 times permissible exposure limits (PELs) in the
headspace of tanks, when vented, they did not pose a hazard to workers because barriers had been
installed around release points and effective controls were in place. The report went on to assert that
even if control measures failed, because ammonia has such a distinct odor and can be smelled at
levels below the PEL, employees could leave the area before any overexposures occurred. 24
Additionally, while acknowledging that “potential carcinogens have been identified as being present
in the tank headspace,” Hewitt postulated that
these chemicals are present at sufficiently low concentrations so that employees can
be protected from overexposure by maintaining their ammonia exposure level below
its PEL [25 ppm]. By protecting employees from an excess exposure to ammonia,
the resulting exposure to other materials would also be at acceptable levels. 25
19 Id.
20 DOE-RL, 1992 TYPE B INVESTIGATION, supra note 6.
21 Id. at 5.15 – 5.19.
22 Elton R. Hewitt, et. al., WESTINGHOUSE HANFORD COMPANY [hereinafter WHC] , TANK WASTE
REMEDIATION SYSTEM RESOLUTION OF POTENTIALLY HAZARDOUS VAPORS ISSUE (WHC-SD-TWR-RPT-001) (June
24, 1996) [hereinafter HEWITT REPORT].
23 Id. at 2.
24 Id. at 17.
25 Id. at 7-8.
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As a result of Hewitt‟s conclusions, the use of supplied air as a precautionary measure was
eliminated entirely at the Hanford tank farms. 26 The Hewitt report continues to guide CHG‟s
industrial hygiene practices today, 27 to the point where workers cannot use supplied air even if they
specifically request to do so because they have smelled, tasted, or suffered adverse health effects
from these invisible vapors that are increasingly inundating the tank farms.
There are many obvious flaws with the Hewitt report. First, Hewitt brushes aside the threats of
carcinogens venting off of the tanks, by asserting that they are minimal and workers can be protected
from them by protecting workers from ammonia. But ammonia is an inorganic chemical, while
many of carcinogens venting from the tanks are organics, such as benzene. Relying on ammonia
monitoring equipment and detection properties to protect workers from organic carcinogens is
illogical.
Second, by focusing on only ammonia and nitrous oxide, Hewitt downplays the synergistic effect of
all the chemicals, brushes aside the significance of the carcinogens venting from the tanks, and
ignores the fact that many of the constituents in the chemical vapors are unknown and not
toxicologically profiled.
Third, relying on workers sense of smell to protect them from toxic vapors is flawed and
irresponsible for several reasons:
Not only ammonia vents from the tanks, but also organics which may not have a
characteristic odor. Carbon monoxide is a deadly poison, which has no odor at
all. Likewise, NDMA is known to vent from the tanks, has no distinct odor, and
is a potential carcinogen that also causes liver damage. 28
Ammonia and organics may vent at different times, meaning that even if workers
left the area when they smelled ammonia, they may not do so when other
compounds vent from the tanks.
By the time a worker identifies a tank vapor such as ammonia, they may have
already been exposed to toxicants within the vapor that could be causing
biological damage to their bodies. Hanford‟s exposure limit for ammonia is 25
ppm; a person generally cannot identify that what they are smelling is ammonia
until its ambient concentration reaches a level of at least 50 ppm. 29
Workers may not smell the ammonia concentrations for a variety of reasons, such
as acclimatization to the odor when the level slowlys increase, olfactory fatigue
when the level is too high to smell (such as when levels concentrate in confined
or closed spaces), or nasal congestion.
26 Jim Jabarra, CHG, Chemical Vapors Solution Team, Formal written answer to question #5 from tank farm
workers, July 2002.
27 Id.
28 CENTERS FOR DISEASE CONTROL [hereinafter CDC], TOXICOLOGICAL PROFILE FOR N-
NITROSODIMETHLYAMINE, CAS# 62-75-9, section 1.1, December 1989, available at
http://www.atsdr.cdc.gov/toxprofiles/phs141.html;
29 CDC, TOXICOLOGICAL PROFILE FOR AMMONIA, CAS# 7664-41-7, section 1.3, September 2002, available at
http://www.atsdr.cdc.gov/toxprofiles.phs126.html; John Harte, et. al., TOXICS A TO Z: A GUIDE TO EVERYDAY
POLLUTION HAZARDS 216 (1991). These sources indicate that while ammonia‟s odor detection threshold can be as
low as 5 ppm, ammonia‟s odor recognition threshold is 50 ppm.
9

Not only does the science of the Hewitt report appear fundamentally flawed, but Hewitt‟s assertions
that “employee exposure incidents had virtually ceased” and that the vapor problem had been
“resolved” were rendered invalid within a matter of months. In August of 1997, GAP released a
White Paper examining negligent exposures to workers at one particular Hanford tank – Tank C-103.
The tank has a history of emitting toxic, cancer-causing vapors into the atmosphere. GAP revealed
that, by the time of GAP‟s report, vapor emissions had resulted in over a dozen known worker
exposure incidents from this tank alone. 30
Finally, a consultant to CHG regarding the 2002-2003 vapor exposure incidents pointed out the flaw
of relying upon the Hewitt report now that the conditions in the tanks have changed due to ongoing
pump and treat activities:
The [Tank Vapor] Industrial Hygiene Personal Monitoring Program Plan . . . appears
to be based, to a large part, on conclusions reached in the 1996 [Hewitt report]. As
noted above, data recently collected . . . indicates that the concentration of selected
organic compounds has increased relative to data collected in 1995. Current pumping
activities were not underway during the period that this data was collected and recent
TDU sampling results suggest a need to evaluate what, if any, these activities might
be having on tank vapor constituents and concentrations. 31
III.
CURRENT CONDITIONS
In the last two years, many circumstances of Hanford‟s operations have changed considerably when
compared with those when the Hewitt Report was released in 1996. First and foremost, the Hanford
tank farms are subjected to an “accelerated cleanup” schedule imposed by the Bush Administration.
The DOE‟s current plan is to transfer most of the solid and liquid radioactive wastes from at least 26
single-shell tanks into double-shell tanks by 2006, and then seal or “close” those tanks. The current
pumping and other waste intrusive activities cause higher rates of vapor release events as the waste is
stirred and transferred at high pressure from tank to tank.
These current activities affect tank farm operations in two main ways. First, as the waste is disturbed
more opportunities are created for vapor releases, potentially exposing workers to the chemical
vapors. Second, as the waste is transferred from tank to tank, the chemical makeup of the vapors
changes, rendering previous tank vapor characterization invalid. CHG has not taken seriously
enough the risks that both of these factors pose to the health and safety of tank farm workers.
In addition to increases in chemical vapor exposures, the rush toward accelerated cleanup also has
resulted in 6 contamination events involving 17 individuals since January 2002. Several of these
incidents involve workers who came in direct contact with tank waste, while others involve
contamination by radioactive dust and cesium.
In an April 22, 2002 letter to CHG threatening to withdraw support for the Voluntary Protection
Program, the Hanford Atomic Metal Trades Council (HAMTC), the collective bargaining agent for
Hanford‟s unionized workers, maintained that CHG‟s acceptance of an “accelerated cleanup
30 Government Accountability Project, BLOWING OFF SAFETY AT THE HANFORD TANK FARMS: TOXIC NEGLIGENCE
AT TANK 103-C, August 1997, at http://www.whistleblower.org; John Stang, Hanford Waste Tank Blasted By
Group, TRI-CITY HERALD, Aug. 12, 1997.
31 Kathie Lavaty, supra note 8, at 7.
10

schedule with DOE-ORP [Office of River Protection] . . . has increased safety risk to workers and the
environment.” 32 HAMTC also criticized the following behavior by CHG:
“Loss of control outside radiological / contamination boundaries. Example:
244A changing wind speed restrictions from 10 mph to 25 mph; historically
10 mph proved less chance for spread of contamination;”
“Accepting risks while exposing workers and the environment to known /
unknown hazards based on the graded approach;”
“300% increase in the number of safety concerns during the last six months.
Exempt and professional staff are also contacting HAMTC with their
concerns;”
“Numerous violations, incomplete work packages, no review of USQ‟s while
proceeding in the face of uncertainty. At the same time, doing away with the
two-man rule, safety equipment is out of calibration and still used.”
According to HAMTC, workers report that “it‟s production over safety.” 33
A. Recent Exposures
GAP has found evidence of 45 chemical vapor exposure events requiring medical attention for at
least 67 people in the 20 months between January 2002 and August 2003. 34 (see Appendix B). There
were at least an additional 75 chemical vapor odor complaints in the same time period. This sharply
contrasts with the 16 exposure events requiring medical attention in the 55 months between July
1987 and January 1992, and amounts to a 750% increase in the rate of significant chemical vapor
exposures.
CHG‟s written policy is that any employee who experiences any type of
symptoms from chemical vapor exposures, such as watering eyes,
burning nose, or headache, is required to notify their supervisor and
report to the nearest HEHF first aid station. 35 When employees just smell
an odor, and do not experience physical symptoms, they are not required
to report to HEHF. GAP has received several reports though, that
numerous tank farm workers experience symptoms such as headaches,
nosebleeds, and metallic taste, but do not report to HEHF for fear of
reprisal or fear of being perceived as troublemaker or as not a team
player.
Of the 45 documented chemical vapor exposure events requiring medical
attention since January 2002, workers have experienced the following
Between January 2002
and August 2003,
workers described the
vapor odors they
encountered in the
following terms:
ammonia, chemical-like,
chlorine, creosote,
diesel-like, foul, musty,
obnoxious, onion, rotten
egg, smoky, unfamiliar,
wet cardboard, and as a
“whiff of organics.”
32 Signed Letter from Tom Schaeffer, President of the Hanford Atomic Metal Trades Commission, to Edward
Aromi, President of CHG, dated April 22, 2003. Written on the front of the letter is “HOLD DO NOT RELEASE 4-
23-03 13:15 JJJ.” [hereinafter HAMTC Letter].
33 Id.
34 This number includes only medical attention required by worker exposure to chemical vapors coming off of the
high level waste tanks. This number does not include a worker smelling an odor without experiencing symptoms,
and does not include non-vapor-exposure events requiring medical attention, such as exposure to or contact with
liquid tank waste, or personal medical conditions that resulted in HEHF visits.
35 CHG, HASP, supra note 7, at 41-42
11

symptoms: burning skin, persistent rash on face, burning nasal passages, burning, running eyes, dry,
productive or persistent coughs, persistent sore or scratchy throat, damaged vocal cords, instant or
persistent headache, metallic taste in mouth, nosebleeds (one lasting for over 20 minutes), nausea,
vertigo, shortness of breath, and increased heart rates.
The chemical vapor exposure events requiring medical attention since January 2002 occurred in the
following tank farms, followed by the number of separate events that occurred there: C Farm (11);
AW Farm (8); AN Farm (7); A Farm (5); BY Farm (3); AP Farm (2); SX Farm (2); U Farm (3); SY
Farm (1); AX Farm (1); AZ Farm (1); Unknown (1).
B. Chemical Vapor Monitoring - CHG Procedures and Practices
Monitoring in Procedure
CHG uses a variety of equipment to monitor for chemical vapors coming off of the high level waste
tanks, and conducts monitoring activities at several different locations.
CHG conducts monitoring activities at several different locations for chemical vapors coming off of
the high level waste tanks. Headspace monitoring (in the dome or vapor space of the tank) is
performed by lowering a probe into the headspace through a portal to determine the potential for
vapor release and to identify and quantify the chemicals in each tank. 36 Source monitoring is
intended to take place close to the source of vapors, such as at exhausters, pump pits, and electrical
cabinets. The data is to be used by industrial hygiene to determine the highest potential levels at
which employees could be exposed. 37 Area
monitoring, also called breathing zone monitoring,
involves collection and analysis of samples in the
general area where personnel work. 38 Personal
monitoring consists of attaching various sampling
devices to an employee during their work tasks and
evaluating any determinant exposures. 39 CHG‟s new
personal ammonia monitor is an example of personal
monitoring; it is worn on the worker‟s clothing and
changes color according to the intensity of the
ammonia exposure the worker is receiving. 40
CHG uses a variety of equipment to monitor for
chemical vapors coming off of the high level waste
tanks. Each instrument available to perform this monitoring is sensitive to varying numbers of
specific chemicals. 41 No one specific monitor is required to detect a particular class of contaminant.
36 Id. at 47.
37 Id. at 46.
38 Id.
39 Id.
40 CHG, Winds Of Change: Weekly Operational Changes, Mar. 6, 2003, Issue 37, p. 1 [hereinafter Winds of
Change].
41 Upon review of a sample of CHG‟s Direct Reading Instrument Survey records, GAP determined that CHG used at
least 8 separate pieces of monitoring equipment (different pieces on different days for different contaminants) during
November and December 2002.
12

The most recently acquired and most commonly used Direct Reading Instrument (DRI) monitoring
equipment used by CHG includes: portable colorimetric ammonia badges, SUMMA canisters, and
hand-held ppbRAE organics readers that present results in parts-per-billion. 42 Some monitoring
results are provided in real time measurements, such as with the ammonia badge or hand held
monitors that instantly display contaminant levels. Other monitoring involves collecting samples and
sending the samples to a laboratory to determine the contaminant levels in the air, such as with
SUMMA canisters.
From the over 1200 chemicals potentially venting from the tanks, CHG has identified 10 primary
potential exposure chemicals as ammonia, nitrous oxide, benzene, butanol, acetone, hexane, xylene,
hydrogen, acid gases, and sulfur containing compounds. CHG asserts that “ammonia is a primary
constituent of concern.” 43
Before any new tank-farm job begins, the industrial hygienist (IHT) conducts a job hazard analysis
(JHA) by considering the location of the work, type of work to be performed, available
characterization data, and source and area monitoring results in order to determine potential
hazards. 44 According to CHG‟s health and safety plan (HASP), the levels of monitoring should
occur as follows:
If source monitoring conducted during the JHA indicates that concentration of
organics exceeds 2 ppm, or ammonia exceeds 25 ppm, then the workers‟ breathing
zone must be monitored while the work is being performed.
If any organics are detected above 2 ppm, or ammonia above 25 ppm, in the
workers‟ breathing zone, then the workers are required to wear a full face cartridge
respirator.
If levels in the breathing zone exceed 25 ppm organics or 300 ppm ammonia, then
conditions are considered immediately dangerous to life and health (IDLH), and the
work area must be evacuated or supplied air must be used. 45
Depending on the workplace conditions identified in the JHA, various controls may be put in place:
engineering (i.e. use of a glove bag or an exhauster), administrative (i.e. establishment of barricaded
areas or requirements that all work be done in pairs), or use of personal protective equipment (i.e.
respirators). 46
Monitoring in Practice
GAP‟s investigation has found several flaws in CHG‟s current monitoring procedures and practices.
These problems place tank farm workers at risk of unnecessary and dangerous exposures to chemical
vapors.
1. Limitations of Monitoring Equipment and Methods
42 CHG, Winds of Change, supra note 40.
43 CHG, HASP, supra note 7 at 9.
44 Id. at 26, 46.
45 Id. at 32-34, Table 2-4.
46 CHG, HASP, supra, note 7, at 10.
13

CHG‟s monitoring equipment has limited capabilities to detect hazards in the workplace
environment, especially since many of the chemicals in the vapors are unknown and uncharacterized.
Most of the sampling that has occurred on the tank headspaces is over seven years old. 47 Very little
characterization of vapor space monitoring has occurred since the recent “accelerated cleanup”
activities began. Only 11 tank headspaces have been sampled since 1999, and none of those
occurred in 2002 or 2003. 48 As retrieval operations disturb and change the chemical constituents in
the tank, monitoring of tank vapors must be revised and readjusted to reflect what is really in the
tanks. One senior industrial hygienist for CHG recently admitted that there are unknown chemicals
and compounds emitted from the tanks that cannot be tested for with CHG‟s monitoring equipment. 49
Even if all the chemicals coming off the tanks are identified and characterized, most of CHG‟s air
monitoring instruments can detect only a handful of compounds at one time, out of potentially 1200
chemicals present in the vapors. 50 The instruments can only be calibrated to a few compounds at a
time and within a certain range (see Appendix C).
There are additional technical problems with the equipment. For example, CHG‟s recently acquired
RAE Systems parts-per-billion photo-ionization organics monitor (ppbRAE) was found to have such
“poor performance” in tests for agent sensitivity that the U.S. Army discontinued testing of this
detector‟s ability to detect the presence of certain organic chemicals; specifically, airborne chemical
weapons. 51 The ppbRAE had reduced sensitivity with increasing use, as the UV lamps used to ionize
the vapor samples for detection were easily contaminated by dust, dirt, moisture, and other exposure
residue. Frequent and thorough cleaning was needed to maintain detector performance. The report
questioned the reliability of the ppbRAE, citing among other things, the need for frequent recalibration,
the wide range of response factors observed, and its inability to detect some tested
chemicals even at IDLH levels. 52
Prior to acquiring the ppbRAE, CHG used the “580-EZ” to perform much lower explosive limit
(LEL) and total organic compounds (TOC) 53 monitoring until late 2002. 54 The 580-EZ was
manufactured to detect a few specific TOCs as well as ammonia. However, this instrument is known
47 See TWINS database, supra note 10.
48 May 6, 2003 letter from Mary Beth Burandt, DOE-RL, to Clare Gilbert, Government Accountability Project,
responding to a request for information on tank waste characterization. 03-ORP-049.
49 [Industrial Hygiene] Senior Safety Manager, CH2M Hill Hanford Group, Sworn Deposition in connection with
Stone, et. al. v. CH2M Hill Hanford Group, filed with the Department of Labor, May 7, 2003, pg. 62 [hereinafter IH
Deposition].
50 L.M. Stock & J.L. Huckaby, supra note 10.
51 Teri Longworth and Kwok Y. Ong, United States Army, Soldier and Biological Chemical Command, DOMESTIC
PREPAREDNESS PROGRAM: TESTING OF RAE SYSTEMS PPBRAE VOLATILE ORGANIC COMPOUND (VOC) MONITOR
PHOTO-IONIZATION DETECTOR (PID) AGAINST CHEMICAL WARFARE AGENTS, SUMMARY REPORT, ECBC-TR,
September 2001, pg. 16, available at http://www2.sbccom.army.mil/hld/downloads/reports/ppbrae_final.pdf
52 Id. at 12-16.
53 GAP has consulted several representatives from various companies that manufacture and sell monitoring
equipment used by CHG, and very few seem to know what TOC stands for. CHG asserts that it stands for Total
Organic Compounds. Some company representatives assert that it stands for Total Organic Carbons. Still other
experts assert that it stands for Toxic Organic Compounds. For purposes of this report, GAP assumes it means
“Total Organic Compounds,” though what exactly that entails, we are still not sure.
54 CHG still relied on the 580-EZ as of December 2002, although less frequently than in previous months. Most
CHG DRI surveys for 2002 list the 580 EZ as the instrument used in its TOC monitoring surveys.
14

to have significant detection problems, and is not even recommended by the company‟s sales
representatives. 55
There are also considerable time and space limitations
to monitoring for chemical vapors in the tank farms.
Monitoring coverage of potential exposures occurs at
only a tiny fraction of the time a tank farm worker is
in the field. According to experts consulted by GAP,
even if CHG were able to monitor for all 1200 of the
chemicals in the tanks, it would still only be
monitoring 10% of a worker‟s potential exposures.
With 136 passively vented tanks, each with numerous
vapor release points, it is virtually impossible to
physically monitor all potential exposures. 56 When
monitoring takes place after the exposure has
occurred, which often happens anywhere from one 57
to several hours 58 after the exposure incident, the
monitoring yields zero protection for the worker.
Additionally, because the human body is several orders of magnitude more sensitive than vapor
monitoring equipment, it is possible for humans to sense contaminants that the equipment is
incapable of registering – not because contaminant levels are too low for the machines to detect, but
because levels come in quick bursts 59 that sometimes are not consistent enough in time to be detected
by monitoring equipment. The significance of this can be explained by examining ammonia, one of
CHG‟s “primary constituents of concern.” Humans can identify ammonia at two thresholds. It is
detectable as an irritant by the human nervous system at levels as low as 5 ppm. Yet, the human
body is not able to recognize and identify the irritant odor as ammonia (an act involving sensory
55 Personal communication between GAP legal intern Billie Morelli and sales representative at Pine Environmental
Services, Inc. 1-800-301-9663, 2:30pm, Aug. 1, 2003.
56 An appropriate formula according to one expert consulted by GAP is as follows: {[(# of chemicals monitored / #
of chemicals in tank headspace vapors) * 100] * 0.1 monitoring time while workers are in exposure areas}.
57 IH Deposition, supra note 49, at 54.
58 For example, one IH DRI Survey notes that the IHT employees had reported smelling foul odors to the north and
south of the AP-farm stack exhauster on Sept. 23, 2002. Yet the IHT did not take ammonia and organics
measurements until 9:05 am the next morning, a minimum of nine hours after the odors were detected. All
measurements were 0 ppm, despite that the IHT also smelled a “slight, brief foul odor.” CHG, IH DRI Survey, ID #
02-2198, Sept. 24, 2002.
59 There are numerous examples since January 2002 where vapors have been released in bursts: CHG, IH DRI
Survey at Tank A-101, Feb. 13, 2002 (“Intermittent ammonia odors present downwind. Non-detectable”); CHG, IH
DRI Survey at AY/AZ Farms, Mar. 28, 2002 (“Intermittent NH3 odors present at and around immediate area of
breather filters”); CHG, IH DRI Survey at Tank AP-102, Sept. 18, 2002 (“Intermittent ammonia odor detected
downwind of stack. NH3

glands tied to memory banks in the brain) until concentrations reach at least 50 ppm. 60 In 70
milliseconds, humans can detect and recognize a 50 ppm or higher dose of ammonia. Yet, even if the
monitoring equipment could measure contaminant levels at a two second time weighted average –
this is orders of magnitude less sensitive than the human body‟s detection capabilities.
Unfortunately, it only takes one quick burst of ammonia (or any other contaminant) at the higher
concentrations for biological damage to occur. 61
2. Inadequate Monitoring Procedures and Compliance
In addition to characterization, equipment, and time limitations, CHG‟s monitoring procedures and
methods are also inadequate and confusing.
First, the HASP states that in conducting the Job Hazard Analysis (JHA), if ammonia and organics
levels are exceeded at the source, then the breathing area should be monitored. 62 Yet there are
numerous sources from which vapors could be venting (tank exhausters, pump pits, riggers, electrical
cabinets, drill strings, glove bags, tank covers, nearby tanks), and IHTs are not required to monitor all
sources. Many of the vapors are invisible and odorless, sometimes making it next to impossible to
tell the source of a contaminant about which a worker is complaining. When an IHT misses an active
vapor release point during source monitoring, the contaminants in the worker‟s breathing zone go
unmonitored and undetected. GAP has even found documented instances where IHTs have
responded to odor complaints (which are by nature in the breathing zone), and declined to monitor in
the breathing zone upon finding source readings within permissible exposure limits. 63
Although the HASP indicates that breathing zone monitoring should be performed when ammonia is
detected at a source in excess of 25 ppm, GAP has reviewed other information that suggests that
ammonia (an inorganic) monitoring is required only after non-specific organics have been detected
above 2 ppm. 64
Additionally, there are several instances where the wrong monitoring equipment was used to measure
workers‟ breathing zone. One senior IHT recently pointed out that in reviewing Direct Reading
Instrument (DRI) monitoring reports, she discovered two situations where IHT‟s had tested for
ammonia in the breathing zone using a colormetric (Draeger) tube rather than the Manning EC-P2
ammonia detector that should be used for area measurements. GAP reviewed DRIs obtained through
60 CDC, TOXICOLOGICAL PROFILE FOR AMMONIA, CAS# 7664-41-7, section 1.3, September 2002. available at
http://www.atsdr.cdc.gov/toxprofiles/phs126.html ; John Harte, TOXICS A TO Z: A GUIDE TO EVERYDAY POLLUTION
HAZARDS, supra note 29, at 216; Conversation with retired PNNL toxicologist Timothy Jarvis, PhD.
61 Conversation with retired PNNL toxicologist Timothy Jarvis, PhD.
62 Id.
63 CHG, IH DRI Survey, ID # 02-0118, April 2, 2002 (This survey was in response to an odor complaint. Source
readings were detectable, but not above HASP limits. No breathing zone surveys were conducted in spite of the
workers‟ complaint of odors).
64 In reviewing CHG‟s Industrial Hygiene Direct Reading Instrument Surveys [hereinafter IH DRI Survey], GAP
has found references to a “Monitoring plan 7B100-MAA-02-022” that apparently instructs the IHT to monitor for
ammonia only after non-specific organics have been detected above 2 ppm. For example, DRI Survey from May 2,
2002 notes: “Area monitoring for ammonia was not performed due to no TOC readings above 2 ppm encountered, in
accordance with monitoring plan 7B100-NAA-02-022.” Several DRIs throughout 2002 mention this plan and/or
follow this procedure (i.e., no ammonia monitoring performed when TOC levels were below 2ppm). GAP has not
yet seen a copy of this monitoring plan; CHG, IH DRI Survey, ID # 03-0225, Jan. 14, 2003 (IHT notes a slight
ammonia smell during maintenance activity, yet only monitoring was for TOCs).
16

FOIA for the months of January through June 2003,
and found a total of 19 instances where Draeger
tubes, rather than the Manning EC, were used to
measure ammonia concentrations in workers‟
breathing zones. 65 In all but two cases, the ammonia
concentrations read non-detectible.
There have been other instances where workers have
entered potentially dangerous situations, such as to
investigate an unexpected exhauster shut-down in
SY farm, without anyone present to conduct any
monitoring for chemical contaminants. 66
An added factor in inaccurate chemical vapor
measurements is the location of the IHT to the source being monitored or the worker complaining of
odors. GAP has received reports from workers that IHTs have taken “source” readings up to a foot
away from the source and area readings several feet away from where the work is being performed.
Such practices increase the likelihood that the IHT will not detect whatever constituents the worker
may smell. Workers have described the situation as similar to sitting around a campfire, where one
person may be inundated by campfire smoke and yet a second person only two feet away may not
notice anything.
Finally, the monitoring procedures CHG has put in place cannot protect workers when those
procedures are not followed, the equipment does not work properly, or decision-makers are
unavailable during possible emergencies:
On March 22, 2002, a heavy smoke odor was present at the work area. 67 The IHT did not
call this in for over an hour.
On April 1, 2002, an odor was present and high levels of organics were detected in the
workers‟ breathing zone. The IHT did not check for ammonia. Instead he wrote a note on
the survey that said, “closed doors to mitigate odors.” 68
On April 8, 2002, the monitor was not working properly, yet the IHT continued using that
instrument. 69
On May 8, 2002, organics levels inside a tent were 27 ppm (respirators are required at 2
ppm). The IHT‟s note does not mention respirators (supplied air is required where organics
are above 25 ppm), but does comment that “operator cut windows into Petro tent to exhaust
out fumes.” 70
65 CHG, IH DRI Survey ID # [hereinafter DRI #] 03-0062 (Jan. 16, 2003); DRI # 03-0113 (Jan. 27, 2003); DRI #
03-1004 (Jan. 27, 2003); DRI # 03-0421 (Jan. 30, 2003); DRI # 03-0132 (Jan. 30, 2003); DRI # 03-0187 (Feb. 10,
2003); DRI # 03-0192 (Feb. 11, 2003); DRI # 03- 0193 (Feb. 11, 2003); DRI # 03-0199 (Feb. 12, 2003); DRI # 03-
0638 (Feb. 19, 2003); DRI # 03-772 (Mar. 12, 2003); DRI # 03-726 (Mar. 17, 2003); DRI # 03-0776 (Mar. 28,
2003); DRI # 03-0786 (Mar. 30, 2003); DRI # 03-01467 (Apr. 5, 2003); DRI # 03-1529 (Apr. 28, 2003); DRI # 03-
1535 (Apr. 29, 2003); DRI # 03-1548 (May 2, 2003); DRI # 03-1565 (May 7, 2003).
66 PER-2003-1121, Mar. 18, 2003.
67 CHG, IH DRI Survey, ID # 02-0078, Mar. 22, 2002
68 CHG, IH DRI Survey, ID # 02-1468, April 1, 2002
69 CHG, IH DRI Survey, ID # 02-0768, April 8, 2002
70 CHG, IH DRI Survey, ID # 02-0235, May 8, 2002
17

On June 14, 2002, headspace organics levels were consistently saturating the monitoring
instrument, reading 9,999 ppm. When the IHT called in to report this, no one answered and
he had to leave a message. When his call was returned, he was directed to proceed with
monitoring, and call back if high levels were received again. A nearby health physics
technician complained of a creosote odor. It wasn‟t until an hour later, when a pressurization
alarm went off, that all personnel evacuated the farm. 71
On November 19, 2002, workers were wearing HEPA respirators in the presence of high
levels of organics. HEPA respirators do not filter organic vapors. 72
In April 2003, the boundary demarcating the Air Monitoring Zone (AMZ) around an
exhauster was reconfigured without the permission of the responsible IH person.
Additionally, a vapor warning sign posted on the Constant Air Monitor (CAM) cabinet inside
the AMZ was removed without the permission of the responsible IH person. 73
3. A Case Study in Monitoring Failure
The limitations of CHG‟s monitoring policies and practices are clearly demonstrated by the fact that
there are several recorded instances that even while the person conducting the monitoring is smelling
odors, the monitoring equipment indicates that contaminant levels are non-detectible. 74 CHG asserts
that this is because workers can smell ammonia at levels that are lower than the equipment
monitoring equipment can detect. Yet, as explained above, ammonia can not be detected until it
reaches concentrations of 5 ppm and cannot be recognized as ammonia until it reaches a
concentration of around 50 ppm. There are several potential explanations for the failure in CHG‟s
ability to detect the contaminants that workers are experiencing:
Workers are smelling something other than ammonia, to which the monitoring equipment is
not calibrated or is incapable of detecting.
The vapors are coming out of the source in intermittent bursts too inconsistent and quick for
the monitoring equipment to register.
Monitoring is not being conducted at the right place – too far from the workers, not at the
source, or not in the vapor plume.
71 CHG, IH DRI Survey,, ID # 02-0313, June 14, 2002
72 CHG, IH DRI Survey, ID # 02-2284, Nov. 19, 2002
73 PER-2003-1591, Apr. 22, 2003.
74 CHG, IH DRI Survey, ID # 02-0024, Jan. 26, 2002 (“Called out to investigate high odor report by power operator
. . . slight odor was apparent . . . readings remained 0 ppm in field.”); CHG, IH DRI Survey, ID #02-0716, Jan. 29,
2002 (“Although no detectable readings were obtained, an odor was detected by the NPO, PO, IH, and IHT.”);
CHG, IH DRI Survey, ID # 02-0107, April 1, 2002 (“Operator asked about organics as he said he smelled a stinky
egg odor in hole when putting monitoring tube down into pit. I told him no organics were detected.”); CHG, IH
DRI Survey, ID # 02-0325, June 19, 2002 (“A mild ammonia odor was detected around breather filter however it
was below the detection level of the instrument.”); CHG, IH DRI Survey, ID # 02-0341, July 2, 2002 (“Checked
around areas where workers were and nothing detected on ammonia instrument, however there was a mild to
moderate ammonia odor detected by me.”); CHG, IH DRI Survey, ID # 02-2139, Aug. 30, 2002 (“All readings were
0 ppm. A very slight brief pungent smell occurred downwind of stack.”); CHG, IH DRI Survey, ID # 02-2198, Nov.
9 2002 (“A slight brief foul odor was smelled approx. 50‟ downwind of stack and no readings were detected.”);
CHG, IH DRI Survey ID # 03-0246, Jan. 22, 2003 (“When doing this job you could smell a faint odor but nothing
detectable on any of the instruments.”); CHG, IH DRI Survey ID # 03-0187, Feb. 10, 2003 (“Mild ammonia odor
detected around AN exhauster area, but instrument showed

The wrong kind of monitoring equipment is being used.
C. Personal Protective Equipment – CHG Procedures and Practices
CHG safety procedures restrict tank farm employees from working in an area without approved
respiratory protection where contaminant levels in the breathing zone may exceed 2 ppm (for three
minutes) for volatile organic compounds (VOC) and/or 25 ppm for ammonia. When the Job Hazard
Analysis (JHA) indicates that employees may be entering an area in excess of these levels, workers
are supposed to be required to use a full face respirator with cartridges, usually the GME-P100.
Additionally, CHG asserts that employees may receive a nuisance mask or a full face respirator at
any time, upon request. 75 The HASP requires workers to wear supplied air respirators when a
potentially hazardous atmosphere exists and any of the following occur:
conditions are unknown or uncharacterized 76
contaminants have poor warning properties 77
contaminant concentrations exceed the respirator canister limits 78
contaminant concentrations are at levels that are considered to be immediately dangerous to
life and health (IDLH). 79 There are three general categories of
respirators used by CHG at Hanford‟s tank
farms. There are dust or nuisance masks; full
face respirators with cartridge filters (CHG
primarily uses the Mine Safety Appliance
GME-P100 Combination Cartridge); and
supplied air (self contained breathing
apparatus (SCBA) or air line respirators).
Despite the sharp increase in recent vapor
exposures, CHG rarely requires workers to
wear basic respiratory protection (much less
supplied air respirators) when going out on a
job. Furthermore, when respirators are
required, they are often insufficient or ineffective. A recent Problem Evaluation Request filed by a
tank farm worker cogently explains the problem:
During the course of my duties as an HPT [Health Physics Technician] . . . I was
asked to respond to an “event” at the 241-C tank farm. An operator had complained
of headache and nausea after being exposed to unknown tank vapors and was
subsequently transported to KADLEC medical center for evaluation. At this time, C-
farm was evacuated. My task was to accompany an operator and an IH technician
into C Farm. I was to evaluate the radiological conditions while the IHT checked for
75 This allowance complies with CHG Radiological Work Permit (RWP).
76 CHG, HASP, supra note 7, at 39.
77 Id. at 38
78 Id.
79 Id. at 38 – 39.
19

vapor sources. Initially, we were told by the on-call IH to wear air purifying
respirators, but operations was unable to obtain these items for us and we were told to
wear nuisance masks instead. Nuisance masks are available to anyone who wants
them any day to keep out annoying odors and are not considered PPE. They should
not be used when responding to abnormal conditions. Considering the press the site
has received in recent days concerning hazardous vapors, the PERCEPTION in this
situation is horrifying. We were told that the nuisance mask was just that and not for
personal protection. If there was no hazard then what were we looking for and why
was a man in the hospital? 80
GAP has found several instances of workers wearing dust masks in conditions which resulted in the
need for medical attention. 81 Additionally, GAP has found several instances where workers were in
environments with very high concentrations of contaminants with no respiratory protection
whatsoever. 82 In fact, the overwhelming majority of the 120 chemical vapor exposures and odor
reports between January 2002 and August 2003 involved tank farm workers who were not wearing
any respiratory protection. GAP has determined that there are several reasons why this is occurring.
First and foremost, CHG is overly-dependent on inadequate monitoring equipment for making
respiratory protection decisions. Even while recognizing that there are “unknown chemical
constituents and compounds” emitting from the tanks that cannot be tested with CHG‟s current air
monitoring equipment, 83 CHG does not consider the working conditions to be unknown or
uncharacterized. CHG instead relies upon its monitoring equipment and methodology to identify job
hazards and determine whether respiratory protection should be used. Despite recurring health
symptoms indicating that workers are being exposed to significant contaminant levels, CHG still
relies on the readings from this monitoring equipment to argue that workers are not being exposed to
dangerous levels.
Second, even when the monitoring equipment measures contaminants in excess of 25 ppm,
respiratory protection often is not required because of a loophole in the safety plan:
80 PER-2003-3194, Aug. 17, 2003.
81 PER-2003-0498, Feb. 3, 2003 (2 workers near AW exhauster pad smelled organic smell that did not register on
meter, then developed burning tongue and lips, lightheadedness, and battery acid taste in mouth. One worker was
transported to Kadlec hospital. IH recommendations for entry into area after the fact were: “All personnel entering
241-AW shall have a 3M 8577 nuisance mask available and ready to don if any vapors not normal are detected.”);
CHG, IH DRI Survey, ID # 03-0197, Feb. 11, 2003 and HEHF Medical Record obtained through FOIA (At C-103,
ammonia concentrations were 300ppm at the source of the pump pit and 0-20 ppm in the area. “Some workers wore
paper type odor mask during work.” One of the workers wearing dust mask reported to HEHF the following day.);
HEHF Medical Records obtained through FOIA, July 1, 2003 (NCO and co-worker smelled strong vapor odor
intermittently. They obtained a dust-type mask with charcoal filter, but could still smell the odor. Both reported to
HEHF complaining of scratchy throats).
82 CHG, IH DRI Survey ID # 03-0076, Jan. 16, 2003 (Area level readings detected ammonia at 50ppm, TOC at
7101ppb, no PPE was worn.); CHG, IH DRI Survey ID # 03-0294 and Air Sampling Summary 03-0294, Feb. 9,
2003 (Area levels readings detected ammonia at 58ppm and TOC at 2.3ppm. PPE was not worn.); CHG, IH DRI
Survey ID # 03-0186 and Air Sampling Summary 03-0186, Feb. 10, 2003 (Area level TOC reached 20ppm, source
TOC readings reached 87ppm, and no PPE was worn.); CHG, IH DRI Survey ID # 03-0324 and Air Sampling
Summary 03-0324, Feb. 21, 2003 (Area level TOC detected at 1.5-2.5 ppm with a “strong musty odor,” No PPE
was worn.).
83 Stated by a senior Industrial Hygienist for CHG. IH Deposition, supra note 49, at 62.
20

The industrial hygienist may consider using time weighted average estimation based
on breathing zone concentrations and stay times to alter the prescription of respiratory
protection. 84
This has resulted in dangerous workplace environments. In one situation at tank BY-105, organics
registered at 12 ppm (action level is 2 ppm) and ammonia concentrations fluctuated between 0 – 60
ppm (action level is 25 ppm) in the breathing area. The IHT‟s note regarding the exposure levels
explains that despite the high contaminant levels, he “did not recommend respiratory protection
because levels above HASP were not sustainable and were infrequent.” 85 In another instance at tank
C-103, the IHT noted that area measurements of organics atop the pump pit elevated and spiked at
levels between 13 – 20 ppm (20 ppm organics is 10 times CHG‟s action level for respiratory
protection). But the IHT noted that these spikes were “never for more than one minute” and the
results of the DRI Survey catalogue the TOC level at 1.7 ppm (1705 ppb). No protective equipment
was worn by the workers. 86
In other situations, work has been performed without respirators in highly contaminated areas, in the
hope that the wind direction would protect workers from overexposure. In one instance, though
ammonia concentrations read 300 ppm at the source, the IHT‟s notes indicate “No mask worn. Work
performed 2 – 3 feet from source on the upwind side.” 87 In another incident, organics were reading
11.8 ppm and ammonia at 44 ppm “downwind from the pit.” The IHT‟s notes reflect that “ammonia
odor was moderate to strong. Informed workers of ammonia odor and to stay upwind when
possible.” 88 As a result of this decision, at least one worker reported to HEHF, complaining of
watering eyes, sore throat, and intermittent cough. 89 In a third incident in July 2002, area organic
levels read 6.2 ppm (action level is 2 ppm), and the IHT “had personnel move away from the area
and upwind until readings reduced.” 90 Placing worker health and safety in the hands of fate and
hoping that wind direction will not suddenly or unpredictably change, is not an appropriate industrial
hygiene practice, and should be discontinued immediately.
Additionally, GAP has received information from several sources that CHG tacitly pressures
employees not to wear respirators. Workers have reported that when some employees have spoken
up at pre-job meetings about their desire to use respirators while working in the farms, management
has responded by choosing someone else to perform the job.
Despite CHG‟s assertions that tank farm workers can receive basic respirators upon request, workers
may choose not to request a respirator of their own accord for a variety of reasons, including pressure
from management not to use respirators, peer pressure, avoiding perception of being weak, not a
team player, or a troublemaker, or because workers believe in CHG‟s stated policy that when
contaminant levels are above recommended exposure levels, CHG will protect its workers. It should
not be incumbent upon workers to request their own respiratory protection when use of that
protection is mandated by law and by CHG‟s own procedures.
84 HASP, supra note 7, at 30.
85 CHG, IH DRI Survey, ID # 02-0556, Feb. 13, 2002.
86 CHG, IH DRI Survey, ID # 03-0186, Feb. 10, 2003 and Air Sampling Survey 03-0186.
87 CHG, IH DRI Survey, ID # 02-0070, Feb. 1, 2002.
88 CHG, IH DRI Survey, ID # 02-0341, July 2, 2002.
89 HEHF Medical Records dated July 2, 2002, obtained through FOIA request.
90 CHG, IH DRI Survey, ID # 02-0358, July 13.2002.
21

Even when CHG does determine that
respirators are needed and provides workers
with them, the respirators often are
inadequate to protect workers from the
conditions they are facing. For instance, the
Mine Safety Appliance GME-P100
Combination Cartridge is NIOSH approved
for only 16 specific compounds. 91 It also
becomes saturated and should be not used in
atmospheres with IDLH contaminant levels
(300 ppm for ammonia or 25 ppm for
organics); supplied air should be used
instead. 92 Yet, workers have reported to
GAP that they have been required to work
in extremely high contaminant levels
wearing only the GME-P100. For example,
this photograph is of two tank farm workers conducting work in a tank pump pit with nothing more
than cartridge respirators. 93 Yet, GAP‟s review of DRI monitoring reports for the months of
September to October 2002 indicate very high levels of organics (up to 238 ppm) and ammonia (up
to > 700 ppm) in several pits. 94 At 700 ppm, the GME-P100 has long since failed.
Additionally, workers persistently have requested Powered Air Purifying Respirators (PAPR) with
hoods, so that their skin is not exposed to the burning irritants. CHG consistently denies such
requests, claiming that they are not available and that they are too bulky.
When workers request supplied air, CHG denies such requests, asserting that by issuing SCBA
respirators, “CHG would [be] violating CHG procedures, DOE orders, and Occupational Safety and
Health Administration (OSHA) regulations . . . .” 95 CHG goes on to explain that SCBA is only
necessary in conditions immediately dangerous to life and health (IDLH), that the monitoring
demonstrates that the vapors do not present such conditions, and that any employee fears of
overexposure are “not reasonable.” 96
Yet, in an April 14, 1992 OSHA report on Tank Farm compliance with OSHA regulations,
conducted in conjunction with DOE‟s Type B Investigation, OSHA informed the tank farm
contractor that “typically at a hazardous waste site, entry into an area of unknown exposure requires
the use of a high level of PPE until site characterization and appropriate monitoring allows
91 Mine Safety Appliance Company, GME-P100 Product Description, available at
http://www.msanet.com/msanorthamerica/msaunitedstates/USrespiratory_protection.html (then type GME P100 into
search box, and click on first result that appears) (last visited August 11, 2003).
92 Id.
93 It is unclear what pit they are working in.
94 The following CHG IH DRI Surveys were all taken in pump pits in September – October 2002: Sept. 12, ID # 02-
2624, Tank AN-102 (238 ppm TOC); Sept. 13, ID # 02-2170, Tank AN-101 (45 ppm TOC); Oct. 1, ID # 02-2703,
Tank A-101 (33 ppm TOC); Oct. 7, ID # 02-2717, Tank U-107 (350 ppm ammonia); Oct. 8, ID # 02-2721, Tank A-
101 (>500 ppm ammonia); Oct. 21, ID # 02-2717, Tank U-107 (>700 ppm ammonia).
95 Jim Jabarra, supra note 26, answer to question #29.
96 Jim Jabarra, supra note 26, answer to question #14: “No, it is not reasonable to assume that any employee will
experience an „over exposure‟ to gases and vapors working in the tank farms.”
22

downgrading to a lower, yet still adequate, level.” 97 OSHA standards for hazardous waste sites and
RCRA treatment, storage, and disposal facilities 98 reinforce this selection criteria by requiring air
supplied respirators for exposures to unknown or inadequately characterized emissions from waste.
In the face of repeated worker complaints of vapor odors and adverse health effects, CHG‟s failure to
require basic respirator use and refusal to allow employees to wear skin protecting or supplied air
respirators upon request is egregious conduct and may constitute “knowing endangerment” under
federal and Washington State law. 99
D. CHG Response to Chemical Vapor Exposures and Concerns
CHG has taken several steps to “curb employees‟ anxiety” 100 about the rise in chemical vapor
exposures, none of which acknowledge the root problems of unknown constituents venting off of the
tanks, inadequate monitoring equipment and procedures, and the alarmingly high potential risks of
contracting cancer from exposure to the tank vapors. 101
In response to numerous Problem Evaluation Requests (PERs) filed by concerned workers, CHG
formed a Chemical Vapor Solution (CVS) Team in March 2002. 102 The CVS Team‟s tasks were to
document employees‟ questions pertaining to vapors and to provide management with suggestions
regarding matters such as vapor identification and control. 103 CHG management acted on the CVS
Team‟s suggestions by writing and publishing formal answers to over 70 of the employees‟ questions
and by hiring two consultants, Kathy Lavaty of Prezant Associates and Harvard toxicologist Rudy
Jaeger, to conduct independent reviews of the industrial hygiene sampling methodologies and of
toxicological issues. CHG developed improved chemical training for interested workers, and
purchased additional organics monitoring equipment such as the ppbRAE. Recently, CHG has
revamped and reactivated the CVS Team, to address the most recent concerns raised in 2003. CHG
also recently invited DuPont Safety Resources onsite to assist in review of CHG‟s industrial hygiene
program. 104
Yet, even a cursory glance beyond the surface of CHG‟s responses indicate that there are no
significant improvements in protection of tank farm worker health and safety since the CVS Team
was formed in March 2002. The answers CHG published for its concerned employees relied on the
97 Allan P. Heins, Rick J. Cee, Stephen W. Prawdzik, U.S. Department of Labor, Occupational Safety and Health
Administration, letter to David Brown, DOE-RL, at p. 5 (April 14, 1992).
98
See 29 CFR 1910.120.
99
The Hanford tank farms are subject to Resource Conservation and Recovery Act (RCRA) regulation by the State
of Washington. RCRA‟s “knowing endangerment” provision states that, “Any person who knowingly transports,
treats, stores, or disposes of any hazardous waste identified or listed under [the Act] in violation of [the criminal
provisions of the Act] who knows at the time that he thereby places another person in imminent danger of death or
serious bodily injury, shall, upon conviction, be subject to a fine of not more than $250,000 or imprisonment for not
more than 15 years, or both.” 42 USC § 6928(e).
100 Email from a CHG Senior IH Safety Manager, to Richard DeBusk and numerous other CHG management. Sept.
6, 2002, 6:51 pm.
101 PNNL, 1997 C-103 Vapor Health Risk Assessment, supra note 13, at 8.1.
102 In November 2002, CHG also formed an Employee Response Team to allow another avenue for employees to
report concerns.
103 Chemical Vapor Solutions Team, Charter, Mar. 20, 2002, modified April 11, 2002.
104 E-mail from Ed Aromi (via CH2M General Delivery) to all CHG Employees and Subcontractors, June 27, 2003,
4:06pm, Subject: “Vapor Concerns Update.”
23

outdated Hewitt report 105 (discussed above) and merely reiterated CHG‟s existing approaches to
monitoring worker health and safety.
The Lavaty review apparently remains in draft form, and while CHG publicizes her conclusion that
CHG‟s monitoring practices are representative of an “acceptable standard of care in industrial
hygiene practices,” CHG fails to publicize her repeated emphasis that conditions have changed in the
tank farms because of recent pump and treat activities, and that there “is an apparent lack of current
monitoring data to adequately characterize potential breathing zone exposures.” 106 She additionally
notes that “recent data suggests that concentrations of certain organic compounds have increased,” 107
that concerns were raised and not answered regarding “a synergistic or unknown, combined effect
[that] could be occurring associated with potential exposures,” 108 and that reliance upon the Hewitt
Report as a basis of industrial hygiene monitoring practices is misdirected given that the “current
pumping activities were not underway during the period when this data was collected.” 109
Similarly, CHG‟s reliance upon Jaeger‟s independent toxicological review 110 as a basis for claiming
conditions are safe at the tank farms is equally flawed. The bulk of Jaeger‟s report consisted of a
three-page letter to CHG, 25 pages of responses to worker questions, and his own 26 page
Curriculum Vitae. In responding to the questions asked by the workers, he referred to employees
concerns as “rumors” 111 and “legends,” 112 suggested that injuries suffered as a result of vapor
exposure were psychological, 113 and responded to direct questions regarding toxicity of the tanks by
asking the rhetorical question, “What definition of toxic applies in this situation?” 114 He additionally
noted that the time he spent onsite was “not sufficient for [him] to examine all aspects of the facility
and its operation.” 115
Since forming the CVS Team, CHG has taken other chemical vapor related actions as well: cost
saving, production oriented actions. Work at the tank farms used to be performed under a “buddy
system,” whereby teams of two were sent into a twelve hour shift in the farms so if anything
happened to one worker, the other could call for help. With the onset of accelerated cleanup and
increased production pressures, CHG did away with the “buddy system” in 2002. This recently had
potentially disastrous effects for one worker, who, in January 2002, was working alone out in
AW Farm late one night with no respiratory equipment. Upon opening a cabinet near a tank
exhauster he encountered a wave of vapor fumes that smelled like onions, which an hour after
the exposure occurred was still measuring 300 ppm ammonia and 24 ppm organics (IDLH
levels). He held his breath, shut the cabinet, and had to rely upon himself to call for assistance,
despite that he was having difficulty breathing and was feeling nauseous. 116 Had he passed out
105 Jim Jabarra, supra note 26, answer to question # 5.
106 Kathy Lavaty, supra note 8, at 3.
107 Id. at 6.
108 Id.
109 Id. at 7.
110 Rudolph Jaeger, Ph.D., Environmental Medicine, Inc., Letter to CH2M Hill Hanford Group, August 26, 2002.
111 Id. at 2 (of letter)
112 Id. at 4 (of Q &A).
113 Id. at 11 (of Q & A) (“Odor by itself is not harmful but the person‟s response or reaction to an odor may result in
harm…. If the odor is a known one, it may be judged to be a positive odor (good) or one that is “bad” (a
malodor)”).
114 Id. at 19 (of Q & A).
115 Id. at 1 (of letter).
116 PER-2003-0129, Jan. 10, 2003.
24

or been otherwise unable to leave the area on his own, he could have suffered significantly more
serious injuries.
Likewise, rather than increasing levels of PPE during pump and treat operations and despite the
soaring increases in worker exposures to chemical vapors, CHG is planning to reduce levels of PPE
and “significantly reduce” administrative controls 117 at the Tank Farms. 118
Excerpt from CHG’s March 19, 2003 Winds of Change newsletter:
Can you believe that Hanford tank farm workers don over 70,000 full sets of Personal
Protective Equipment (PPE) a year?!! WOW! Wouldn‟t it be nice not to have to do that
quite so often? If you agree, then, you‟re in luck!
ESH & Q folks are working on a plan to reduce the level of PPE required in some areas
of the tank farms. Due to improved work practices, the general work areas in the tank
farms contain only low levels of contamination. . . . This will allow access to
contamination areas wearing only gloves, shoe covers, and canvas booties.
. . . Why are we doing this? There are lots of benefits, including reduced injuries / heat
stress, waste reduction and cost savings.
Questions About Monitoring Data 119
GAP has obtained documentation indicating that CHG has maintained haphazard chemical vapor
monitoring procedures and recordkeeping that workers can be exposed to toxic chemicals on the job
and then left with unreliable and un-interpretable exposure records. Contaminant readings on
instruments have gone unrecorded, leaving health-affected tank farm workers with no toxicological
dose record and insufficient data to provide to Hanford‟s third party administrator for worker‟s
compensation, Contract Claims Services, Inc. (CCSI). The nature of the problem is best explained
by example.
On the morning of January 16, 2002, several electricians were digging a trench for electrical conduit
near tank U-111 in the U Tank Farm. Tank U-111 is located about 50 yards to the southwest of Tank
U-108. U-108 had been pumping since early November 2001, which disturbed the waste & gases
inside the tank. An Air Monitoring Zone (AMZ) barrier had been erected closely around the lid of
the tank U-108 because of the pumping, which was then extended out another 5 feet after a small
crack in the foam covering the tank‟s pump pit and concomitant high ammonia levels were
117 Administrative controls are “changes in work procedures such as written safety policies, rules, supervision, and
training with the goal of reducing the duration, frequency, and severity of exposure to hazardous chemicals or
situations.” http://www.ilpi.com/msds/ref/administrativecontrols.html
118 CHG, Winds of Change, Weekly Operational Changes, Mar. 19, 2003, Issue 38, p.3. Additionally, the new
Documented Safety Analysis (DSA), to be implemented on or before April 2002, will reduce the number of
administrative controls from 24 to 16, and the number of Limiting Conditions for Operation from 11 to 3. Id, at 1.
119 April 7, 2005 Note: This section of the original September 15, 2003 report has been revised to reflect
information learned by GAP since the release of the report.
25

discovered in December 2001. Tank U-108 also sits at a slightly higher elevation than the
surrounding tanks, meaning any chemicals coming out of the tank could drift downward in the
workers‟ direction in inverted weather conditions. The morning of January 16 th was cold, damp, and
foggy (< 32 degrees F) with little to no wind.
The electricians began the day with a pre-job meeting, where they discussed what they would be
doing that day and what they might encounter on the U-111 job. While someone mentioned that
there had been odors in the area, no one mentioned (nor were the electricians aware) that there was a
hole in the foam at U-108 from which vapors were leaking. After the pre-job meeting, the
electricians spanned out to dig at various points of the trench. Electrician Steve Lewis was working
adjacent to U-108. He had a head cold and could not smell the noxious odors that began to waft out
of U-108 and down toward his co-workers. He was wearing whites, gloves, a hat, and safety glasses.
As the other electricians began to notice and complain about the smell, they backed away from the
immediate area and started yelling and waving for Lewis also to leave the area. Due to the odor
complaints, the person in charge (PIC) decided to shut down the job and, after getting Lewis‟
attention, the entire crew left the area until it could be monitored by an Industrial Hygiene Technician
(IHT).
Meanwhile, en route back to the electricians‟ building, Lewis‟ skin was bright red and burning, he
tasted a metallic taste in his mouth, and developed a headache. Lewis was transported to first aid
(HEHF) at 12:14 pm, and on the way the PIC contacted the Industrial Hygiene department to convey
that there were odors at the U-111 trench jobsite. 120 The IH supervisor then dispatched an IH
technician (IHT) to perform monitoring at that location. At 12:37 pm, a second electrician who had
smelled strong odors was transported to HEHF. 121
At around 1pm, the IH supervisor received a call back from the IHT who had been dispatched to
monitor at the job site. The IHT reported that although there were no detectible odors, 0 ppm
ammonia, and 0 % LEL at U-111. The supervisor called the IHT‟s monitoring results into the
Command Control Center, which recorded the “U-Farm” readings in the CCC log. 122
Later in the day, when Lewis had returned to work from HEHF, he and other co-workers spoke with
a different IHT (aka: IHT #2), who had been working in the A-Farm all day. IHT # 2 stated that it
was no wonder that that day‟s job at U-108 was closed down, because there was a crack in the foam
of the tank‟s pump pit lid, and they had measured at least 600 ppm down in the pump pit. The crack
hadn‟t been repaired yet because of the wet, rainy weather. Though that was the first time Lewis and
his co-workers heard about the high readings and crack in the foam, IHT #2 was referring to a
measurement taken at least a month earlier. On January 22, 2002, a work package was generated to
fix the crack in the foam at Tank U-108. 123
Several months after the January 16 th event, when Lewis‟ symptoms had not subsided and he felt as
if his “lungs were weeping” – he tried and was unable to obtain the monitoring results from his
exposure event. The closest he could obtain was monitoring that occurred at 3:30 pm (when the wind
120 CHG, Command Control Center Log, Jan. 16, 2002, 1214 entry.
121 CHG, Command Control Center Log, Jan. 16, 2002, 1237 entry.
122 CHG, Command Control Center Log, Jan. 16, 2002, 13:00. (“[IH] reports O2 levels normal, NH3-0%, TOC –
0% in U Farm. IH also reports no noticeable odors.”)
123 Rapid Maintenance request, #6432, Jan. 22, 2002 (“Apply Armaflex and Duct Seal at U-108”).
26

had picked up since the 11:00 am exposure) on a completely different job at U-108. 124 Despite
Lewis‟ repeated requests, the 1:00 pm U-Farm monitoring results mentioned in the Command
Control Center log were not and could not be produced because the IHT that had taken and reported
the measurements had never recorded them by uploading them into the Direct Reading Instrument
database.
Herein lies a major failing in CH2M Hill‟s Industrial Hygiene exposure monitoring program. DOE
and CHG have procedures detailing Industrial Hygiene monitoring procedures, especially following
an exposure to toxic chemicals that results in the need for medical attention. Yet despite the
existence of these procedures, CHG has no mechanism for enforcing them, and they appear to be
routinely disregarded with little to no consequences, as happened in Mr. Lewis‟ case.
In an ideal situation, the IHT who reported to the site of Lewis‟ exposure would have measured the
contaminants with a Photo-Ionization Detector (which is a Direct Reading Instrument), an ammonia
reader (Manning) and a combustible gas meter. The procedure calls for the IHT to download the
information into the DRI database, and then given the exposure records to the affected worker within
15 days as required by OSHA 1910.1020. 125
Prior to going out on any job, industrial hygiene technicians calibrate their instruments to ensure
accuracy. This calibration information (e.g. the calibration gas) is recorded and entered into the
database. When actually measuring, the IHT must record the time and location at which the
measuring occurred. This should be done on standardized DRI forms, but many Hanford IHT‟s jot
down their locations and the time in little spiral notebooks. An IHT may take several readings
throughout the day or over several days, and all are stored in the Direct Reading Instrument itself.
The IHT then connects the instrument to the database via a USB port, at which time all readings are
uploaded and stored in the database and deleted from the instrument. The database automatically
assigns a chronological number to the various DRI readings, and the IHT must then fill in the
additional information such as calibration and location information. Besides uploading the
monitoring data in to the database, the only other way to remove the information from the DRI is
manually.
The lack of a DRI from the 1:00 reading at U-111, coupled with the fact that there is no break in the
number sequence of the DRI database, suggests that no records were ever destroyed in Mr. Lewis‟
case. Instead, no records were ever created. Without the recorded data to back up the exposure
monitoring, many questions also remain:
What instruments did the IH Tech use to monitor? Were they the right instruments for the
conditions?
For what chemicals was the IH Tech monitoring? Were they the same type of chemicals
emitted from that particular tank? Was tank characterization information reviewed prior to
taking measurements?
Where exactly did the IHT monitor? Was it at the source or in the area? What was the exact
time?
124 CHG, IH DRI Survey, ID # 02-0011, Jan. 16, 2002, at 3:10 pm.
125 29 CFR 1910.1020(e)
27

With the failure to record this information on a standardized form and to upload this information into
the DRI database, there is nothing to prove that any measurements were even taken, much less taken
accurately. Consequently, the integrity of any such data is suspect. Additionally, as discussed
earlier, data that is uploaded into the database is often so poorly retained, catalogued, and reviewed
that it is unlikely to add up to a comprehensive story of exposure.
CHG and CCSI are now contesting Lewis‟ workers‟ compensation claim by arguing that he was not
exposed to the levels he claims, when in fact CHG failed to follow its own monitoring procedures
that should have documented his exposure levels.
CHG consistently fights worker compensation claims following exposures, even when doctors have
claimed that illnesses are the result of exposures. CHG fought another electrician‟s worker‟s
compensation claim (for consistent nosebleeds and chemical rhinitis), in spite of “work related”
diagnoses from two of the three CCSI-referred physicians and from a fourth physician at Harborview
Medical Center‟s Occupational and Environmental Medicine Program in Seattle. In fact, following
pressure from the lawyer representing CHG and CCSI‟s interests, two of the three CCSI-referred
“Independent Medical Examiners” changed their original conclusions of “work related” symptoms to
“not work related.” The electrician‟s L & I claim was denied.
Interestingly, Harborview recently wrote a letter to CHG‟s Vice President asking a number of
questions pertaining to, among other issues, outdated tank vapor characterization data, 126
questionable industrial hygiene practices, 127 and CHG‟s reasons for not requiring supplied air when
employee exposure cannot be reasonably identified or estimated The author of the letter went on to
explain:
Given my limited understanding of the chemical instability of the Tank Farms tanks;
the presence of high concentrations of ammonia and nitrous oxide in the tank
headspace, as well as a complex mixture of over 40 chemicals (including
carcinogens); the opportunities for leakage through openings in close proximity to the
worker‟s breathing zone; and the limitations of the waste tanks profiles, I would
recommend the use of supplied air respiratory protection for employees working in
close proximity to these tanks in the Farms. This is why I am interested in your
exposure assessment approach and respiratory protection selection rationale. 128
A Chilled Work Environment
Workers who do complain about exposures and actively seek protective equipment have been
subjected to a pattern and practice of retaliation, reprisal, and various humiliations - all which create
a chilling and hostile working environment and deter reports of safety violations and medical injuries
at Hanford tank farms. Some workers have filed formal complaints with the Department of Labor
126 Letter from Nancy Beaudet MS, CIH, Industrial Hygienist at Harborview‟s Occupational and Environmental
Medicine Program to Kathy Lombard, Vice President, CHG, July 24, 2003 (“The waste tank chemical profiles were
conducted over 7 year [sic] ago. Is there more recent information?”).
127 Id. (“Why was the scope of the exposure assessment limited to ammonia? I understand ammonia is present at
high concentrations in the headspace and likely serves as a good warning chemical. However, since carcinogens,
nitrous oxide, a significant number of irritants, and other chemicals are also documented in the Tank Profile, a more
comprehensive exposure assessment seems reasonable.” (internal citations omitted))
128 Id. (Internal Citations Omitted).
28

alleging that they have been retaliated against by CHG for raising health and safety concerns
pertaining to the tank vapors. 129 One worker was subjected to harassment, ridicule, taunting and a
hostile work environment due to his complaints about tank vapor exposures. He was subjected to
comments from co-workers that he was a “whiner,” that he was lazy, and a malingerer. He also
found a note on his car warning him to “leave it alone,” as well as a full body suit stuffed into his
car.
Additionally, other workers, not only electricians but also pipe-fitters and operators, have informed
GAP of similar retaliation by CHG for attempting to raise vapor-related concerns. Rather than
providing adequate respirator protection so that workers concerned about their own health and safety
can work in the tank farms, CHG refuses and then denies overtime work in non-tank farm areas to
those needing respirators. Overtime work can account for over 30% of a tank farm worker‟s annual
income. Because the safety culture is so broken, many workers are even afraid to report when they
have been exposed to vapors in the first place.
HAMTC‟s April 2003 letter to CHG also criticized CHG for creating a “chilling effect and culture”
where “employees feel cover-ups are taking place with limited critiques, no formal investigations or
lessons learned.” 130 The letter also states that CHG has “limited HAMTC and sanctioned employee
involvement in work planning, post-job reviews, and programs that affect worker‟s safety and
health.” 131 One can only wonder whether it is this same “chilling effect and culture” that is causing
the HAMTC letter to remain indefinitely on “Hold Do Not Release” status.
IV.
HANFORD ENVIRONMENTAL HEALTH FOUNDATION
Unfortunately, the minimization of the extent and significance of tank farm chemical vapor exposure
incidents does not appear to end at the boundary of the tank farms. It is more systemic, reaching into
the realms of the onsite health care provider, Hanford Environmental Health Facility (HEHF) and
perpetuated by certain upper level HEHF staff and management. As GAP has investigated these
incidents and complaints, a number of issues have arisen that are of great concern. 132
1) Some upper-level HEHF staff have made it clear that they recognize that HEHF‟s success
depends upon pleasing other DOE subcontractors. In one incident in mid-August 2002, a
subcontractor safety employee formally questioned the medical legitimacy of an HEHF
health care provider‟s medical diagnosis, when that diagnosis resulted in a reportable work
restriction for an employee. When HEHF personnel got upset about the inappropriate
behavior of the safety technician, the now director of HEHF responded in a group e-mail that,
“We are just now getting business from this subcontractor, and they could go outside the
fence. As far as I am concerned, I will explain why I do things in a humble and appreciative
129 GAP represented 3 electricians in their case against CH2M Hill Hanford Group, Case # 2002-ERA-00004, filed
with the Department of Labor, Office of Administrative Judges.
130 HAMTC Letter, supra note 32.
131 Id.
132 Each allegation asserted below is based upon documents provided to and reviewed by GAP and upon direct
testimony to GAP by HEHF patients, tank farm workers, and current and former HEHF staff.
29

manner because my success here depends upon theirr [sic] business returning to this
facility.” 133
2) HEHF health care providers and staff describe receiving pressure from HEHF management to
minimize the number of “recordable” 134 injuries and diagnoses. This pressure is sometimes
overt and explicit and at other times more structurally implemented.
a. One HEHF health care provider describes attempting to write a restriction of “No
work around beryllium” for a patient with lung disease. Within minutes of writing
the restriction, the health care provider was informed by HEHF‟s health educator that
“HEHF management has instructed that we don‟t create recordables.” The health
educator then ordered the front desk attendant to change the restriction.
b. Medical restrictions for patients are often developed in collaboration with companies
onsite 135 and then applied in a uniform fashion to patients, from which deviation is
rarely acceptable. Often medical restrictions merely restate existing action levels for
protection from contaminants, and offer no additional protection to workers. 136
c. Under HEHF‟s “case management” policies, certain categories of workers are only
permitted to see certain doctors – for example, all tank farm workers must see Dr.
Smick. In March 2003, the then HEHF director, Dr. William Brady, explained that
“All tank farm workers are now directed to follow-up with Dr. Smick to answer their
concerns and to settle down problems / issues raised by local „clinical ecologists.‟
These pseudo-specialists conduct tests including hair analysis, skin biopsies, and
doing chelation.” 137
d. The following scenarios often occur within HEHF after a worker is injured or
exposed on the worksite:
1. Safety representatives “phone ahead” to discuss the “situation” with Dr.
Smick, prior to the patient reporting for medical evaluation and/or
133 E-mail from Smick, Larry B., DO to HEHF health care providers, Thursday, August 15, 2002, Subject: “RE: Eye
Patches” (emphasis added).
134 Recordable incidents (work related injuries, illnesses, and exposures) become recordable when a prescription for
medication or therapy, a medical diagnosis, or a medical restriction is written. Reported recordable incidents can
directly affect Hanford contractors‟ status for receiving DOE bonuses based on “safe work habits” and “zero lost
work hours.”
135 In one worker‟s HEHF medical records from January 2003, Dr. Larry Smick noted: “We discussed the tank farm
restriction at great length. I reviewed the restriction that has been developed by CHG’s Health and Safety
program.” HEHF progress notes written by Dr. Smick for patient Lloyd Stone, Hanford tank farm worker, Jan. 13,
2003. (emphasis added).
136 A typical restriction often used for tank farm workers states, “No exposure to chemicals at or above ½ (action
level) the occupational exposure limits, either the TLV or the PEL, whichever is more stringent.” CHG‟s action
level for protection of workers from ammonia is 25 ppm and from organics is 2 ppm. So such a restriction, written
for a worker who has been exposed to tank vapors resulting in nosebleeds, contact dermatitis, or respiratory distress
offers no additional protection for the worker. HEHF‟s Larry Smick, DO has explained away this discrepancy to
HEHF providers by pointing out that, “The I.H. people actually accompany the workers with direct measuring
equipment to ensure protection.” E-mail from Smick, Larry DO to HEHF health care providers, Jan. 23, 2003,
Subject: “Important Notice.”
137 HEHF, Industrial Hygiene / Medical Meeting Minutes, Mar. 6, 2003.
30

treatment. 138
2. While a patient is in triage with the HEHF nurse, the safety representative
from the contractor meets behind closed doors with Dr. Smick (or another
health care provider if Dr. Smick is away from the clinic) without the
patient‟s knowledge. 139
3. Safety representatives often instruct the clerk to have the patient see a
particular provider that they think will be friendlier to the company. 140
4. HEHF often sends the tank farm workers right back into the conditions that
caused them to seek medical assistance in the first place, with no additional
PPE requirements. 141
5. HEHF management (case management) routinely meets with Contract
Claims Services, Inc.(CCSI, Hanford‟s third party insurer for worker
compensation claims) and company safety representatives regarding
occupationally ill or injured workers. These meetings are held to discuss
and review medical records outside the presence of the patient, their
knowledge, or their consent.
e. GAP has received reports from HEHF staff and patients that the following process
often occurs in “case management” cases such as tank farm vapor exposures:
After a patient is seen by an HEHF provider, the patient departs the
facility with copies of the Record of Visit (ROV) documenting the
reason for the visit as “occupational.” The patient also receives a
similar copy for his/her manager. However, a different copy is
sometimes sent electronically to the patient‟s employer (the safety
representative) within 24 hours. Frequently, when Dr. Smick was not
the examining provider the service code is changed to a “nonoccupational”
visit, 142 after a phone call to Dr. Smick by the safety
representative. The contractor‟s safety department is immediately
notified of the change, electronically, or sometimes by fax, by case
138 This is clearly demonstrated in a Jan. 23, 2003 e-mail from Larry Smick to HEHF health care providers: “To all
providers – Mr. Steve Lewis may be coming down this afternoon to see a provider. I will not be here due to an L&I
hearing in Kennewick. He is a tank farm worker who was asked to return to tank farm duties. I believe he may
want a work restriction requesting no tank farm work but I am not certain. I received the “heads up” call from his
supervision. Remember, no tank farm work is an administrative accommodation and not a medical restriction.”
139 According to reports received by GAP, on some occasions, the clerical staff is notified of a patient‟s name and
instructed to call immediately when and if the patient shows up. When the patient arrives, case management is
notified and soon thereafter a safety representative and/or a human resources representative from their company
arrives. The company representatives will meet with Dr. Smick immediately before or after the patient is seen by
Dr. Smick. Often the patient is unaware of the situation and does not recognize the company representatives.
140 As an accredited medical facility, HEHF is required to post the “Patient‟s Bill of Rights.” In essence this
document outlines the right to prompt, fair and comprehensive medical treatment, and includes the right of the
patient to refuse service by a particular provider. GAP has been informed that this is not always honored. On at
least one occasion related to us, a patient stated that he did not want to see a particular doctor and asked to arrange a
different provider. When HEHF staff inquired about this request, the staff person was told was told that the choice
of doctor “was arranged at the request of the patient‟s company” and the patient was required to see him.
141 This concern was raised over a year ago, in December 2001, in a Problem Evaluation Request (PER), but does
not seem to have been remedied and is still occurring. PER-2002-0164.
142 HEHF staff have reported to GAP that they have been approached by their supervisor and instructed, per Dr.
Smick, to change the diagnoses in a stack of medical records to “non-occupational.”
31

management. The patient receives their “altered” copy in the plant
mail, days later, many times not understanding the change of service
made it the visit a “non-occupational” un-recordable incident. 143
“I went out and I sat down, and then when the lady printed it out, none of that stuff that he said was on there. It just
said: Return to work, no restrictions. And so I said, "Excuse me, could you show me the folder? That's not what I
understand that Dr. Smick was saying. He was going to put on my restriction, when I was in there, into the
interview with him." And she went over and got my folder and she said, "Oh, yes, it does have a lot. It does have a
page here that Dr. Smick wrote. It's all crossed out, and he just wrote underneath it: Return to work, no restriction."
I have never seen a shenanigan that filthy in my life. That is my personal all-time worst that I've ever seen”
- Lewis Deposition, Mar. 11, 2003, at 146:19 – 147:8.
3) HEHF recently developed a policy to make it easier to send patients for psychological
examinations if they persist in asserting that their illnesses are work related. HEHF
management recently redefined work suitability examination procedures to make it an
“automatic referral” to Behavioral Health Services for psychological evaluation, if one of a
given set of “criteria” are met, including the following:
a. “Three occurrences of the same injury . . . .;”
b. “Two restricted, lost time injuries in one year, or three . . . in a consecutive three-year
period;”
c. “When a medical condition is not resolving as expected;”
d. “When there is no objective evidence of pathology, yet impairment disability
continues.” 144
Several of the tank farm vapor victims with whom GAP has spoken each report that they
have suffered multiple incidents of vapor exposures. Under HEHF‟s policy, if they went to
HEHF after each exposure they would be sent for psychological evaluation, shifting the focus
away from the vapor exposures and onto the psychological condition of the worker.
Additionally, according to a physician consulted by GAP, automatic referral to BHS when
“no evidence of pathology, yet impairment disability continues,” appears to violate the spirit
and letter of the Americans with Disabilities Act.
4) As of June 2002, HEHF no longer permits union representatives, friends, or family to
accompany workers in medical exams. Workers have reported intimidating, threatening, and
143 One worker reported that Dr. Larry Smick wrote a less protective medical restriction in the progress notes than
what the physician told the worker he was writing. When he asked the receptionist at the front desk to see his
progress notes, there was a large “X” across what Smick told the worker he had been writing, and underneath was
written, “Return to work, no restriction.” When the worker came back a few days later with his union steward to
view the progress notes again, they were no longer in the file. Upon asking the receptionist, she said, “Oh, we don‟t
have . . . the one he X‟d out. Well, we shred that.” Deposition of Steven K. Lewis, Mar. 11, 2002, p. 145-152, Tom
Young, et. al, v. CH2M Hill Hanford Group, Case No. 2002-ERA-0004.
144 E-mail from Smick, Larry B., DO, Wed. Sept. 11, 2002, Subject: “Question about the “work ability” monitoring
program.” GAP has been unable to determine whether or not this policy has been formally implemented, though the
e-mail outlining it instructs the administrative staff to “pull up the procedure for the work suitability examination
and make the following changes. Please consider adding a section that if the criteria I have listed below is met (you
can list the criteria), the worker will be evaluated by case management physician or his designee, behavior health
services, and by exercise physiology.” Id., Subject, “RE: Question about the “work ability” monitoring program.”
32

demeaning behaviors by certain HEHF health care providers during these (un-witnessed)
exams. 145
“A problem has occurred regarding the occasional requests for union stewards to accompany workers when an
examination is done. My feeling is that in more cases, they are an adverse influence on the outcome of the
examination. It seems to be an attempt to intimidate the provider. . . . We need to develop a standard policy that can
be defended. I have had a few poor outcomes when stewards were in attendance because they don‟t keep quiet.”
- July 23, 2002 e-mail from HEHF’s Larry Smick, DO to then HEHF Director Bill Brady, MD
5) Certain HEHF physicians are accused of attempting to explain away worker exposure
symptoms by alleging that they are psychological or allergic reactions. The Hanford Site
Medical Director‟s Report for FY 2002, asserts that “HEHF has taken a major interest in
trying to resolve” workers‟ health concerns about exposure to tank vapors: “A person‟s sense
of smell is a likely candidate for that person developing perceptions which may not be true. . .
. In the case of tank farm workers, the vapors may not be harmful to workers. However,
convincing the workers that the odor is harmless is a more difficult task. HEHF‟s
psychologists have been working on this aspect of the problem . . . .” 146 In fact, the HEHF
tank farm worker case manager recently instructed HEHF health care providers to,
“Remember, it is not so much of the science as it is drawing of blood that makes exposure
victims whole again.” 147
6) A July 2002 study conducted by HEHF examined effects from exposure in tank farm workers
and concluded that medical test results from Tank Farm workers were not significantly
different from other Hanford workers or the general public. 148 However the study was not
peer reviewed and is statistically biased. The authors defined 39 out of 64 abnormal test
findings from Tank Farm workers as “normal variants” and “clinically insignificant,”
arbitrarily discounting them from the analysis. Furthermore, no analysis on the rate of
abnormal test findings was performed on Hanford workers or the general public. CHG
publicly references this 2002 study as evidence that tank farm workers are not suffering long
term health effects from chemical vapor exposures. 149
7) HEHF‟s dismissive, lackadaisical approach to tank vapor exposures was documented in Rudy
Jaeger‟s investigation: “When I met with HEHF, no adverse health impact of tank farm
145 For example, one tank farm worker reports that he requested that his union steward be allowed to accompany him
in a January 2003 HEHF medical appointment, for the worker found it odd that CHG had scheduled the appointment
for HEHF to re-write his work restriction when his “No work in Tank Farms” restriction wasn‟t up for reassessment
until March 2003. The union steward was not permitted to accompany the worker into Dr. Smick‟s office. The
worker had issues with the new restriction as it was written, for fear that the protection of “administrative controls”
(an instrument technician monitoring ammonia levels while he was working) would not protect him from exposures,
but would only alert him to the fact that he was being exposed (he had had six exposures in one year before his first
restriction was written). Upon refusing to accept the pre-written restriction without modification, the worker was
told Dr. Smick, “Fine, I‟ll do whatever you want; but I am just trying to save your job.”
146 HEHF, Medical Surveillance Department, Hanford Site Medical Director’s Report for FY 2002, 5 (prepared
under Contract DE-AC06-98RL13686 (Mar. 2003)).
147 E-mail from Larry Smick, DO, to HEHF health care providers, June 9, 2002, Subject: Exposure situation
yesterday.
148 William H. Brady, MD, MPH, HEHF, Medical Surveillance Report: Tank Farms, July 32, 2002.
149 ORP and CHG Briefing to GAP on Tank Vapor Issues, April 10, 2003, 10:30, 2440 / 2664. Reference to the
HEHF Report was made in CHG‟s power-point presentation.
33

elated work other than some persons being overweight was described by them. However,
based on that meeting, I came away with the opinion that the current state of health of
individual tank farm employees by job description or category, work location, and specific
trade may be incompletely documented or recorded. I judged the state of epidemiologic
surveillance to be inadequate.” 150
Q: And what if the industrial hygienist tells you, when you go to them, that we don't know exactly what they were
exposed to, that there are chemicals out there that we just -- we don't know what they are, what their properties are?
Have you ever dealt with that situation?
A: No. I would go back and you'd have to tell me what they were exposed to; otherwise, how do I assay for effect?
Q: That's exactly my question. How would you, if they told you: We don‟t know?
A: You know, if they don't know, then it's unlikely that the exposure would be significant, because most industrial
hygienists can estimate exposure.
-Smick Deposition, May 8, 2003, at 17-18
a. CHG‟s HASP confirms Jaeger‟s assertion, in that while workers “shall” report to the
nearest Health Service Center when they feel they have been exposed to noxious
vapors or vapors in excess of PELs, “an entry will be made into the medical
surveillance tracking log for continued follow-up, as deemed appropriate by medical
and industrial hygiene staff.” 151
b. Additionally, DOE designates certain categories of workers as “tank farm workers”
for recording purposes, despite that many other employees (such as construction
workers) may be exposed to tank vapors. HEHF provides different medical treatment
and follow-up for workers, depending on their administrative categorization, rather
than on their complaints of exposure and symptoms. Therefore, a pipefitter and a
construction worker, standing side by side, both exposed to the same chemical
vapors, will receive differing medical care by HEHF. According to HEHF‟s Dr.
Larry Smick, “Non tank farm workers exposed to odors are not scheduled for routine
follow-up. ONLY TANK FARM WORKERS.” 152 This has been difficult and
confusing for the HEHF staff to implement, 153 and does not appear justified from a
medical care standpoint.
8) Controversial cases, such as tank vapor cases or cases in litigation, were, until recently, kept
in two different locations. The main medical record was stored in one location, while a
150 Rudolph Jaeger, supra note 110, at 2.
151 CHG, HASP, supra note 7, at 42 (emphasis added).
152 E-mail from Smick, Larry B. DO to HEHF health care providers, Tues. Apr. 29, 2003, Subject: “REGARDING
TANK FARM EXPOSURES.” (emphasis in original).
153 One HEHF health care provider responded to Smick‟s request by stating, “I am a little unclear. [Another health
care provider] and I both saw Fluor Northwest crafts people who were putting up scaffold in tank farms and smelled
an odor. Since they were not tank farm workers per se, we each scheduled them to return and see us here at 200 W
next week . . . Is that wrong? Or, because they were in the farms, they are to see you? Or, because they are not
really tank farm workers, they don‟t need a personal visit? It is confusing . . . .” E-mail from one HEHF health care
provider to Larry Smick, DO and other health care providers, Wed. April 30, 2003, Subject: “RE: REGARDING
TANK FARM EXPOSURES.”
34

second “case management file” was stored in a different location, under lock and key, and
contained the physician‟s personal notes, safety information and correspondence, IH
information, and other communications pertinent to the patient‟s medical condition. These
records were not available to the patient and were not reviewable by other health care
providers. This policy was changed only after objections by outside medical personnel.
9) There also have been instances where patient confidentiality apparently has been breached.
GAP has received reports of multiple incidents of documents disappearing from medical
files, medical files being left in other buildings, copies being generated and stored in other
departments, and safety representatives receiving copes of patients medical files. In other
cases, access by patients to their own medical files has been denied and/or delayed – in one
case a patient was forced to engage the services of an attorney to gain access to his files.
a. In one instance in November 2002, HEHF shared the medical results of beryllium
tests on five prisoners with the Pacific Northwest National Laboratory apparently
without those patients‟ consent. 154 PNNL had donated a refrigerator, which turned
out to be contaminated with beryllium, to the Columbia Basin College (CBC). CBC
contracted with Coyote Ridge Correctional Facility to use prison labor to transport
the refrigerator from PNNL to the college. When it was discovered that the
refrigerator was contaminated with beryllium, the five Coyote inmates who had
transported the item were given blood tests at HEHF for beryllium contamination.
HEHF management shared the test results with PNNL apparently without the
patients‟ consent, and even inquired of PNNL whether the one inmate with
uninterpretable results should be retested. 155 This apparent breach of confidentiality
is especially disturbing given the U.S. government‟s notorious history of
experimentation on prisoners.
V. SYSTEMIC NATURE OF PROBLEM
The Occupational Safety and Health Administration (OSHA) has no jurisdiction 156 at the Hanford
site, or any site in the DOE complex, as per the Atomic Energy Act of 1954 and subsequent DOE
enabling legislation. Rather, DOE‟s own health and safety program operates in lieu of the
enforcement and inspection program of OSHA. Through DOE Orders 440.1 and 5480.4, DOE
contractually mandates that its contractors and subcontractors comply with the requirements of
OSHA embodied in 29 CFR 1910, 1928, 1926, and 1928. 157 This means that at sites such as
Hanford, worker health and safety is protected by DOE‟s application and enforcement of OSHA‟s
Hazardous Waste Operations and Emergency Response (HAZWOPER) standard. 158 Yet, since
154 This information was obtained by GAP through a Freedom of Information Act request dated May 17, 2003, RL
2003-0145. GAP reviewed the consent forms contained in the FOIA response, and was unable to find any consent
given for HEHF to discuss their medical results with any outside agency other than the prisoners‟ employer.
155 Id.
156 Except for the investigation of whistleblower discrimination complaints filed pursuant to the Nuclear
Whistleblower Protection Act, 42 USC §5851.
157 DOE‟s OSHA policy at the Hanford Site was in an e-mail sent from the DOE Communications Office to all
Hanford Employees. Jan. 17, 1997, Subject: DOE OSHA POLICY AT THE HANFORD SITE.
158 29 CFR 1910.120. A background paper prepared by the U.S. Congress‟ Office of Technology Assessment
investigates and explains in depth the protection of worker health and safety at DOE facilities, the relationship
between DOE and OSHA, and how the HAZWOPER regulations should be and are enforced. U.S. Congress, Office
35

OSHA does not have right-of-entry or inspection jurisdiction at DOE facilities, and therefore cannot
issue citations at DOE facilities or impose financial or criminal penalties if DOE contractors fail to
comply with HAZWOPER and other standards, 159 workers must rely solely upon DOE to protect
their health and safety.
Yet DOE‟s professed ability to self-regulate is rendered ineffective by an inherent conflict of interest:
protecting worker health and safety potentially impacts the cleanup deadlines set by the DOE and
costs the DOE more money. Additionally, the DOE‟s cleanup budget is in the same Congressional
budget account (the “050 account”) as the defense budget. Every dollar saved on nuclear weapons
cleanup potentially can be spent on nuclear weapons research and development.
The U.S. Congress‟ Office of Technology Assessment made the following observations about DOE‟s
conflict of interest and its ability to exercise adequate oversight of its contractors:
“Over the years, a special “partnership” developed between DOE and its M&O‟s
[Manufacturers and Operators] that has greatly complicated DOE‟s oversight of
its contractors. About 90% of DOE‟s total budget is spent on contractors,
primarily those who manage the NWC [Nuclear Weapons Complex]. This
amounted to $17.6 billion in fiscal year 1990.” 160
“The lack of strong, centralized control over DOE contractor organizations will
hinder efforts to ensure consistent and comprehensive implementation of OSHA‟s
Hazardous Waste Operations and Emergency Response (HAZWOPER) standard
and other health and safety standards during the NWC cleanup.” 161
The health and safety of Hanford tank farm workers is directly affected by this conflict of interest, as
evidenced by the dozens of workers recently exposed to noxious, potentially cancer causing chemical
vapors without adequate respiratory or skin protection. The DOE remains conspicuously silent in the
face of these skyrocketing exposure rates, and has offered little to no relief for workers seeking
protection of their own health and safety. In fact, three tank farm workers filed numerous concerns
with the DOE‟s Employee Concerns Office in 2002 about the working conditions at the tank farms –
CHG‟s inadequate monitoring, the failure of CHG to properly characterize and toxicologically
profile the tank waste and vapors, the refusal to provide supplied air and failure to require basic
respirators. In each case, DOE either has failed to respond, closed the concerns because the workers
had whistleblower retaliation cases pending in the Department of Labor, 162 or referred the concerns
back to CHG for investigation.
of Technology Assessment [hereinafter OTA], HAZARDS AHEAD: MANAGING CLEANUP WORKER
HEALTH AND SAFETY AT THE NUCLEAR WEAPONS COMPLEX, OTA-BP-O-85 (1993) [hereinafter
HAZARDS AHEAD].
159 OTA, HAZARDS AHEAD, supra note 161, at 11.
160 Id. at 62.
161 Id. at 57.
162 Three tank farm employees have cases pending in the U.S. Department of Labor, brought under the Energy
Reorganization Act and other environmental statues, for whistleblower retaliation by CHG. Those three employees
are represented by GAP, Tom Young, et. al, v. CH2M Hill Hanford Group, Inc., Consolidated Case # 2002-ERA-
00004, filed with the Department of Labor, Office of Administrative Judges. Yet, while they assert that they have
been retaliated against by CHG for raising concerns in the first place, the subject matter of those concerns is entirely
a DOE oversight matter. Since DOE enforces HAZWOPER and worker health and safety, workers should be able
36

By 1992, with the comprehensive Type B Investigation, the DOE and the Tank Farm contractor were
on notice as to the problems of chemical vapor exposures. Yet, this is not the first time since 1992
that GAP has had to release a report on toxic vapor exposures and the risks to which the DOE and
contractors were exposing workers. In August of 1997, GAP released a White Paper examining
negligent exposures at one tank, C-103. 163 By the time of GAP‟s report, C-103‟s vapor emissions
had resulted in over a dozen known worker exposure incidents. GAP‟s report detailed how, in
rushing to meet a negotiated cleanup “milestone,” or deadline for treating the toxic emission from C-
103, Hanford management ignored the concerns and recommendations of its own scientists and
engineers, and implemented a “treatment” program that failed to treat the problem and may well have
made it worse. 164
Now, in 2003, workers are again being exposed to toxic vapors at an alarming rate, and again due to
DOE pressure to comply with cleanup deadlines. From the initial 16 exposures in 4½ years that
triggered the 1992 Type B Investigation, we now have 45 vapor exposure incidents requiring medical
attention in the last 20 months. By failing to exercise health and safety oversight, and by failing to
enforce its own orders and regulations, DOE and CHG have created a new generation of exposure
victims.
What is most discouraging to many long-time observers of Hanford and the DOE is the recurring
failure to institute long-term cultural change that would result in a safer working environment and
greater public acceptance of Hanford‟s work. Instead, Hanford unabashedly repeats the mistakes of
its past and continues the cycle of preventable victimization, even while proclaiming that it is driven
by a policy of “Safety First.” The failure of Hanford to take to heart the Lessons Learned from the
16 vapor exposure incidents a decade ago, resulting in recriminatory reports, bad publicity, and shortlived
safety reforms, has led to an even more chronic exposure crisis ten years later. The situation
with the DOE is reminiscent of another federal agency that is resistant to change: the National
Aeronautics and Space Administration (NASA). NASA recently made headlines again for a second
preventable space shuttle disaster involving the Columbia. The Columbia Accident Investigation
Board was explicit in its August 24, 2003 report about what it considered a root cause of the
accident:
NASA managers believed that the agency had a strong safety culture, but the Board
found that the agency had the same conflicting goals that it did before Challenger,
when schedule concerns, production pressure, cost-cutting and a drive for evergreater
efficiency – all the signs of an “operational ”enterprise – had eroded NASA„s
ability to assure mission safety. The belief in a safety culture has even less credibility
in light of repeated cuts of safety personnel and budgets – also conditions that existed
before Challenger. NASA managers stated confidently that everyone was
encouraged to speak up about safety issues and that the agency was responsive to
those concerns, but the Board found evidence to the contrary . . . . 165
to approach DOE to fix the root of the problem about which they have been raising concerns – in this case, the
health and safety conditions at the Hanford Tank Farms.
163 Government Accountability Project, Blowing Off Safety at the Hanford Tank Farms: Toxic Negligence at Tank
C-103 (Aug. 1997) at http://www.whistleblower.org; See also, John Stang, Hanford Waste Tank Blasted by Group,
TRI-CITY HERALD, Aug. 12, 1997.
164 Id.
165 Report of the Columbia Accident Investigation Board, Aug. 2003, p. 202
37

Like NASA, Hanford has fallen victim to the same production and schedule pressures, the same
complacency, and the same culture of intolerance of dissent. Like the situation with NASA, it is up
to Congress and the Executive Branch to take long overdue action to end the self-serving regulatory
regime that tolerates and even encourages the lack of safety at Hanford.
VI.
REMEDIES AND POSSIBLE SOLUTIONS
There is a fundamental conflict of interest inherent in DOE‟s simultaneous role as designer / enforcer
/ beneficiary of “accelerated cleanup” deadlines and as protector of worker health and safety in
meeting those deadlines. Worker health and safety at DOE facilities has been sacrificed for decades
because of this conflict of interest. 166 It is time for Congress to take steps to remove DOE from
oversight of occupational safety and health, since both the DOE and its contractors are incapable of
self-regulation. Truly independent oversight and enforcement of worker health and safety is needed
at Hanford and at all DOE facilities.
In the meantime, GAP has several „engineering control‟ recommendations for how to improve the
problem of chemical vapor exposures at the tank farms. Vapor exposures at tank farms can be
significantly reduced or even eliminated by employing some additional safety technologies. A
number of laser or infrared remote chemical detection and analysis technologies have been developed
for detecting hazardous chemicals, radionuclides, and biological weapons. One such instrument has
been tested at the tank farms already. A 1998 Hanford Technology Demonstration Fact Sheet 167
reports that an Open Path-Fourier Transform InfraRed (OP-FTIR) instrument was tested in the tank
farms with a Computed Tomography-Remote Optical Sensing of Emissions (CT-ROSE) system
developed by University of Washington researchers. The Fact Sheet indicates that the system can
detect ammonia and 6500 other chemicals at a distance of up to 500 meters, providing an early
warning system to keep workers out of areas with presently venting tanks. Preliminary tests seemed
to indicate that this technology could be used successfully, but for some reason, was not permanently
implemented at the tank farms. DOE should require continued testing and implementation of this
sort of remote chemical analysis and detection technology.
Another device recommended by workers with whom GAP has spoken is a thermal imaging camera,
such as the Scott Thermal Imager II, used by firefighters to see through smoke. The device translates
heat energy (via temperature variations as minute as .007 of a degree) into visual images, which
could assist the IHTs in detecting the point source and plume location of what are normally invisible
chemical vapors. Once the exact location of the vapor is detected, the source could be effectively
sealed or monitored.
Active venting of more tanks on a regular schedule may also help prevent vapor exposures.
Passively vented tanks can potentially emit vapors whenever atmospheric pressure inside the tank is
higher than outside of the tank. If all the tanks were actively vented every few hours or some other
regular, planned time interval, tank farm workers would simply not be scheduled to work in the area
or downwind of the area during the time period where tanks are scheduled to be venting.
166 Multiple expert and government reports have documented pervasive and serious failures in DOE‟s protection of
occupational safety and health. See, Office of Technology Assessment, HAZARDS AHEAD, supra note 161, at 11.
167 At http://www.hanford.gov/techmgmt/factsheets/demos/1998/ftir.html
38

In addition to implementing the above engineering controls, the tank farm contractor has a duty to
require the use of basic respiratory equipment and allow the use of all practically available PPE, up
to and including SCBA, should the worker request it.
GAP‟s suggestions for how to improve overall the chemical vapor issue include the following:
1) CHG should formally acknowledge to tank farm workers that:
there are unknown constituents currently venting from the tanks from which
employees are not being protected;
that the hundreds (and potentially thousands) of chemicals in the tanks more than
likely have synergistic effects upon each other;
that PNNL scientists have found a potentially very high risk of contracting cancer
from exposure to these vapors, and that that risk is not only limited to tank C-103;
that CHG‟s monitoring equipment cannot monitor for anything close to all the
constituents of concern potentially venting from the tanks, and that while such
monitoring is still necessary, it should not be what determines the level of PPE
until a more accurate understanding of the hazards posed by the tank vapors is
completed;
that elevated monitoring records and readings have been suppressed or gone
undocumented and that such behavior is not condoned and will cease
immediately;
that workers who have raised concerns about health and safety issues at the tank
farms have sometimes been retaliated against in the past, and that such behavior
is not condoned, and will cease immediately.
2) CHG should require all workers entering the tank farms to wear, as minimum protection,
full-face respirators with combination cartridges or a similar respirator that is equally as
protective.
3) CHG should provide workers with supplied air and PAPR with hoods upon request, as a
matter of right. This would allow workers who have been staying out of the tank farms
for fear of their own health and safety to return to work, and would send a clear message
to the employees that CHG is taking the vapor concerns seriously.
4) CHG should reinstitute the "buddy system," requiring all tank farm work to be performed
with at least two workers.
5) CHG and DOE should perform characterization on the headspace vapors of each tank
that has been disrupted in any way by ongoing accelerated cleanup operations and then
make that information readily available to employees and others.
6) CHG and DOE should acquire and implement the laser or infrared remote chemical
detection and analysis technologies and the thermal imaging camera discussed above.
7) CHG should implement formal monitoring procedures whereby all measurements are
recorded and documented and cannot be altered. Any CHG employee found altering or
39

covering up monitoring data, or providing false reports concerning monitoring results
should be held accountable.
8) CHG should give a more active role to the unions in all matters that affect worker safety
and health.
9) DOE and CHG should work with the Washington Department of Ecology to create more
protective air permits that work to control the release of hazardous vapors, and implement
creative solutions to comply with those permits. Air permits should be written and
required for the off-gassing of tanks and for the tank evaporators. The site boundary for
tank farm permits should be the tank farm perimeter, not an amorphous line 3 to 5 miles
away from the chemical vapor sources – as is the current situation. Washington
Department of Ecology should take a more active role in enforcing regulatory compliance
with existing and future air permits – since there is no other agency that is doing so at the
present time.
10) The Washington State Attorney General‟s office should initiate an investigation into the
serious allegations of knowing endangerment, falsification of illness and injury reporting
requirements, deliberate impediment of worker illness and injury compensation claims,
and other potential violations of state law relative to the operation of the Hanford site.
11) Washington State Labor and Industries should cease relying solely on the diagnoses of
CCSI-Identified “Independent Medical Examiners” in worker compensation requests
from Tank Farm workers for exposure to chemical vapors. The Washington State
Attorney General should open an investigation into the systematic denials of worker
compensation requests for occupational illnesses from the Hanford site, and into the role
of CCSI and HEHF in facilitating and ensuring those denials.
12) The DOE Office of Inspector General and the Washington State Attorney General should
open an investigation into the practices of HEHF‟s upper management. DOE should
consider revoking HEHF‟s contract or at least replacing upper management with
physicians and psychologists more protective of their patients‟ health than securing their
own business contract.
40

APPENDIX A:
Chemical Vapor Exposure Incidents Requiring Medical Attention:
July 1987 – January 1992
APPENDIX A – July 1987 – January 1992
No. Date Location Description
1. 1987
07.03
C Farm 3 employees smelled strong odor. Developed headaches, difficulty breathing,
and burning noses. Reported to first aid. Several weeks of missed work and one
employee lost 40% lung capacity.
2. 1987
07.15
C Farm 2 NCOs detected odor, and experienced irritating feeling in throats and reported
to first aid. RTW-NR.
3. 1987
09.04
AW
Farm
RPT smelled an odor and immediately exited the area. Experienced a nosebleed.
RTW-NR.
4. 1987 SY Farm Operator smelled ammonia vapors. Sent to first aid, no symptoms. RTW-NR.
11.09
5. 1989 C Farm Operator smelled an odor, was sent to first aid as a precaution. RTW-NR.
01.06
6. 1989
08.16
7. 1989
09.28
8. 1990
04.19
9. 1991
03.15
10. 1991
09.06
11. 1991
09.16
12. 1991
09.17
13. 1991
09.17
14. 1991
10.12
15. 1991
12.04
16. 1992
01.28
C Farm RPT smelled a “musty” smell and held breath until was upwind. Experienced a
headache and nausea. Went to first aid and was given oxygen. Went to hospital
for further evaluation. RTW next day.
AP Farm Operator smelled ammonia and developed a headache. Said he had an identical
experience a few days earlier. First aid, given oxygen. Transported to hospital
for further evaluation.
AX Farm HPT and several others smelled foul odors. Noticed a helicopter spraying
pesticides nearby. Developed nausea, headache, as did one other individual who
reported to the ER. No link was made between helicopter and symptoms.
C Farm HPT inhaled unknown vapors and developed a headache. Sent to first aid. RTW
same day.
C Farm 3 employees smelled unidentified odor and became nauseous. Reported to first
aid. Nausea and sore threats. Sent to Kadlec for further evaluation.
C Farm KEH Construction worker inhaled unknown vapor; sent to first aid for
evaluation. Subsequent monitoring of farm detected no vapors. RTW short time
later
C Farm 2 insulators exposed to unknown vapors while constructing a greenhouse. Both
experienced nose, throat and eye irritation and were sent to first aid. RTW same
day.
C Farm 2 KEH Construction workers noticed unknown odor. Sent to first aid; RTW
same day.
SY Farm 1 HPT inhaled a vapor that he identified as partially ammonia. Reported to first
aid; irritation of upper airway observed. RTW same day.
BY Farm 1 HPT noted strong unidentified odor, became nauseous and reported to first aid.
Near
BY/BX
farm
RTW same day
5 KEH construction workers noticed unusual odors of rotten eggs or battery acid.
Some reported symptoms of nausea, dizziness, chest pains and unusual taste in
mouths. All sent to first aid; 2 sent to Kadlec Hospital but returned home same
day. One individual reported heart palpitations. Later monitoring of site with
PID detected no organic vapors. Air monitoring indicated ammonia readings of
15 and 40 ppm.
41

APPENDIX B:
Chemical Vapor Exposure Incidents Requiring Medical Attention:
January 2002 – August 2003
APPENDIX B: January 2002 – August 2003 Exposure Incidents
No. Date Location Description
1. 2002
01.11
SX Farm Smelled ammonia and organics. Developed continuous headaches and
persistent sore throat.
2. 2002
01.16
U Farm Worker in ammonia smell for 20 min. because had head-cold and couldn‟t
sense smell. Burning skin, chronic throat problems, weeping lungs, increased
heart rate.
3. 2002
01.29
SX Farm Plumber and PF smelled ammonia. Told to leave area because there was no
IHT present.
4. 2002 AX Farm Electrician smelled ammonia, felt burning skin and developed nosebleed.
01.30
5. 2002
02.08
A Farm Worker overcome by chemical vapors and stumbled backward and had
difficulty breathing. Developed red, burning skin. Reported to HEHF.
6. 2002 BY Farm Working and smelled ammonia. Later developed a headache, nosebleed,
02.13
chemical rhinitis.
7. 2002 A Farm Strong ammonia odor and then developed sore throat, skin and nasal irritation.
02.23
8. 2002
02.27
9. 2002
02.28
10. 2002
04.03
11. 2002
06.14
12. 2002
06.25
13. 2002
07.16
14. 2002
08.09
15. 2002
08.11
16. 2002
8.27
17. 2002
09.09
18. 2002
10.01
A Farm
AN Farm
Exposed to two plumes of a chemical odor. Eyes ran and burned, metallic
taste, skin felt hot with burning sensation, nosebleeds. Rash present for three
months, even with medication.
Diesel smell coming from dirt. Felt nauseated. Reported to first aid.
U Farm Several workers experienced a chlorine-like smell. Unsustained organics
readings of 30 ppm at the source. 3 workers taken to first aid as a precaution.
AW Shop Chemical exposure and worker reported to first aid. Returned to work with no
restrictions.
C Farm Pungent odor from breather filter at C-103. Reported to HEHF.
A Farm Cloud with strong ammonia smell from pit. Eyes watered at the time,
developed sore throat and intermittent cough later. Went to HEHF.
AP Farm Smelled ammonia smell while walking through farm. Felt nauseated and nose
burned so exited farm. Developed headache later at HEHF.
BY Farm Ammonia smell coming from tank riser and breather filter off and on for 2.5
hours. Nasal irritation at the time; persistent throat clearing and coughing for
about 22 days following. Reported to HEHF.
AP Farm 3 employees smelled a strong chemical odor and immediately left the area,
holding breath. Reported to HEHF. The IHT suffered headache,
lightheadedness, mild cough, and a metallic taste in mouth.
BY Farm NCO taking readings. Smelled ammonia odor, which caused nose to burn, odd
taste in mouth, and spitting. Developed a headache and a cough. Chronic
change in voice. Sought first aid. Had chest x-ray.
A Farm Inhaled vapor while walking through A Farm. Began coughing and
expectorating.
42

APPENDIX B: January 2002 – August 2003 Exposure Incidents
No. Date Location Description
19. 2002
10.31
C Farm Smelled unfamiliar odor. Within 5 minutes, developed headache, sore throat,
burning sensation in nose, shortness of breath, and a dry cough. HEHF and
RTW-NR.
20. 2002 SY Farm NPO was taking readings when smelled a strong ammonia-like odor; became
11.13
21. 2003
01.10
22. 2003
01.14
23. 2003
01.20
24. 2003
01.27
25. 2003
01.28
26. 2003
02.03
27. 2003
02.06
28. 2003
02.10
29. 2003
02.11
30. 2003
02.11
31. 2003
02.12
32. 2003
02.13
33. 2003
02.20
34. 2003
02.24
35. 2003
02.24
36. 2003
02.27
37. 2003
03.03
38. 2003
04.16
39. 2003
04.28
AW Farm
AW Farm
AN Farm
light-headed. Reported to HEHF.
NCO opened cabinet and felt dizzy, breathed in strong onion-like odor.
Personal physician said lungs burned by ammonia. Felt jittery, couldn‟t stop
falling asleep, cold, clammy, and pale.
NCO exposed to ammonia and organics at primary stack exhauster. Filed and
L&I claim.
HPT & NCO starting exhauster when experienced a “whiff of organics,”
Experienced headache and metallic taste in mouth. Read 300 ppb organics.
HEHF – RTW – NR.
AN Farm Exposure to unknown organics. Reported to first aid where they drew blood
and gave him a urine test.
AW Farm Worker was assisting crafts in adjusting valves and smelled strong ammonia
odor. Developed a scratchy throat and cough that persisted for 2 days.
Reported to HEHF and RTW-NR.
AW Farm Operator and IHT smelled vapors near exhauster pad, experienced vapor
exposure symptoms. One person transported to Kadlec for evaluation.
AN Farm Exposure to unknown organics; same person and in same spot as 01.27.03
incident. Did not report to first aid because thought dose might be too low.
Later in evening had to go to ER because of heart problems.
AN Farm
C Farm
AN Farm
C Farm
C Farm
C Farm
C Farm
NCO entered control room and smelled ammonia odor; had burning eyes and
metallic taste in mouth. Taken to Kadlec for evaluation.
Installing for camera for four hours wearing a dust mask and noted an
ammonia like odor. The next day developed a headache. Reported to HEHF.
IHT reported odor like wet, musty cardboard while sampling. Developed
throat irritation while sampling air. Evaluated at first aid and RTW-NR.
Worker smelled strong odor in supply van and then developed metallic taste in
mouth.
Vapor exposure; metallic taste in mouth for 3 days, tightness in chest and
difficulty breathing. Reported to HEHF.
NCO and IHT were inside van when odors seeped in; metallic taste in mouth,
burning nose.
Vapor exposure. Had a headache for four days following. Went to HEHF.
AW Farm NCO and IHT could smell ammonia and organics at primary stack exhauster.
An L & I was opened for this event.
C Farm PF experienced headache and metallic taste in his mouth. Reported to HEHF –
RTW.
C Farm 2 employees exposed to vapors. Headache, burning nose, metallic taste in
mouth.
U Farm Workers excavating towards tank dug through layer of black cinder material
and smelled offensive odor. Complained of feeling lightheaded. 5 workers
reported to HEHF.
AN Farm 2 Fluor craftspeople were putting up scaffolding in tank farms and smelled an
odor. Reported to HEHF.
43

APPENDIX B: January 2002 – August 2003 Exposure Incidents
No. Date Location Description
40. 2003
05.09
C Farm 20 minute nosebleed at work following 2 weeks of work in C Farm wearing
nuisance mask because of tank vapors. Classified as work-related injury.
41. 2003
06.08
Unknown
location
At least 3 workers exposed, at least one of whom reported to Kadlec and two
of whom reported to HEHF on 06.09.03.
42. 2003 AW Farm 2 NCOs were applying tape over an area on the primary exhauster to reduce
07.01
vapor smell and smelled strong intermittent odors. Developed scratchy
throats. Reported to first aid.
43. 2003.
07.16
AZ Farm Worker in AZ farm smelled an unknown odor and experienced a headache.
Reported to first aid.
44. 2003
07.29
AW Farm Electrician smelled an “obnoxious” odor while working on the exhauster.
Reported to first aid.
45. 2003.
08.17-8
C Farm Three workers experienced strong odors in the C farm and experienced nausea,
headache, throat irritation, and a metallic like taste after experiencing strong
odors in the tank farms.
Abbreviations:
ER
HEHF
HPT
IHT
Kadlec
L & I
NCO
NPO
PF
RTW-NR
Emergency Room
Hanford Environmental Health Foundation
Health Physics Technician
Industrial Hygiene Technician
Local hospital in Richland
Labor and Industries (Workers Compensation)
Nuclear Chemical Operator
Nuclear Process Operator
Pipe-Fitter
Returned To Work – No Restriction
44

APPENDIX C:
TANK VAPOR MONITORING EQIPMENT: NOVEMBER – DECEMBER 2002
FLAMMABLE
GAS, CO, and O 2
MONITORING
ORGANICS
MONITORING
AMMONIA
MONITORING
INSTRUMENT
Industrial Scientific
iTX-484
Industrial Scientific
LTX-310
Industrial Scientific
MX-251
Industrial Scientific
TMX-412
RAE Systems
ppbRAE
Thermo
Environmental
Instruments, 580-EZ
Ammonia Detector
Tube
Manning Systems
EC-Portable
CAPABILITIES
Simultaneously monitors
LEL and up to five other
gases from a list of
seventeen.
Simultaneously monitors
LEL, O 2 , and one other
gas from list of ten.
Simultaneously monitors
for LEL and O 2 .
Simultaneously monitors
LEL, O 2 , and two other
gases from list of six.
Simultaneously monitors
for organics and some
inorganics (less sensitive)
in ppb range using PID
technology.
Monitors for organics and
some inorganics (less
sensitive) in ppm range
using PID technology.
Qualitatively detects NH 3
in 5 – 700 ppm range.
Monitors NH 3 in the range
of 5-500 ppm. Utilizes
Electrochemical
technology.
TANK FARM USE
Used only for LEL
monitoring.
Used only for CO
monitoring.
Used only for LEL
monitoring.
Used only for LEL, O 2 ,
and CO monitoring.
Used for organics
monitoring. Calibrated
to Isobutylene (thus
most sensitive only for
those compounds similar
to isobutylene.
Used for organics
monitoring . Calibrated
to Isobutylene (thus
most sensitive only for
those compounds similar
to isobutylene).
Used for NH 3 detection.
Calibrated to NH 3 , 25
ppm. Used for NH 3
detection.
Instrument list compiled by GAP according to Direct Reading Instrument Survey reports received through
FOIA requests. November and December were chosen because they are the most recent data GAP has
received to date. The HASP directs IHTs to first monitor for LEL, then TOC, then ammonia if indicated
by TOC results. Other instruments were used from time to time during other months. Capabilities data
was obtained from manufacturers‟ websites and through conversations with manufacturer sales
representatives.
Legend:
LEL: Flammable Gas Lower Explosive Limit ppm: Parts Per Million
NH 3 : Ammonia ppb: Parts Per Billion
CO: Carbon Monoxide O 2 : Oxygen
PID: Photo-Ionization Detection (detects “ionization energy”)
45

“During the course of my duties as an HPT [Health Physics
Technician] . . . I was asked to respond to an “event” at the 241-C tank
farm. An operator had complained of headache and nausea after being
exposed to unknown tank vapors and was subsequently transported to
KADLEC medical center for evaluation. At this time, C-farm was
evacuated. My task was to accompany an operator and an IH
technician into C Farm. I was to evaluate the radiological conditions
while the IHT checked for vapor sources. Initially, we were told by the
on-call IH to wear air purifying respirators, but operations was unable
to obtain these items for us and we were told to wear nuisance masks
instead. Nuisance masks are available to anyone who wants them any
day to keep out annoying odors and are not considered PPE. They
should not be used when responding to abnormal conditions.
Considering the press the site has received in recent days concerning
hazardous vapors, the PERCEPTION in this situation is horrifying.
We were told that the nuisance mask was just that and not for personal
protection. If there was no hazard then what were we looking for and
why was a man in the hospital?”
- Problem Evaluation Request filed by a Hanford Tank Farm
worker on August 17, 2003 (PER-2003-3194)
46

”[For
five
months
my]
lungs
just
wept.”
--SL,
Tank
farm
worker
,
descri
bing
the
lastin
g
effect
s of a
severe
tank
vapor
exposu
re
GOVERNMENT ACCOUNTABILITY PROJECT
www.whistleblower.org
West Coast Office
National Office
1511 Third Avenue, Suite 321 1612 K. Street NW, Suite 400
Seattle, Washington 98101 Washington, D.C. 20006
Phone: (206) 292-2850 Phone: (202) 408-0034
Fax: (206) 292-0610 Fax: (202) 408-9855
47